A Multisite Injection Is More Effective Than a Single Glenohumeral Injection of Corticosteroid in the Treatment of Primary Frozen Shoulder: A Randomized Controlled Trial.

PURPOSE: To investigate the possible effects of multisite injection therapy around the shoulder and prospectively compare the pain relief, range of motion (ROM), and functional scores of randomly selected patients with primary frozen shoulder using the American Shoulder and Elbow Surgeons score and the University of California-Los Angeles score after the completion of a standard physiotherapy program. METHODS: Seventy-six patients with primary frozen shoulder were randomly divided into 2 groups based on the treatment: multisite injection and single injection. In the multisite-injection group, the glenohumeral joint and posteroinferior capsule, subacromial space, posterosuperior capsule, biceps long head, and coracohumeral ligament were injected with a combination of 2 mL of triamcinolone acetonide (40 mg/mL), 4 mL of bupivacaine (0.5%), and 34 mL of saline solution. The glenohumeral joint in the single-injection group was injected with 1 mL of triamcinolone acetonide (40 mg/mL) and 2 mL of bupivacaine (0.5%). Patients in both groups underwent physical therapy using the same protocol. Patients were evaluated for pain (visual analog scale score), functional status, and active and passive joint ROM at 1, 3, and 6 months and 1 year after the injection. RESULTS: The follow-up rate was 82.6%, and significantly lower VAS scores were recorded in all periods in the multisite-injection group compared with the single-injection group (P = .01). In terms of active and passive ROM, the follow-up results were significantly better in the multisite-injection group (P < .05). Significantly higher functional scores were recorded in the multisite-injection group (P < .05). CONCLUSIONS: Both treatments were effective in patients with primary frozen shoulder. However, the multisite-injection technique provided better pain palliation, better ROM restoration, and better functional results than the single glenohumeral injection in patients with primary frozen shoulder who were treated with the same physiotherapy regimen. LEVEL OF EVIDENCE: Level I, prognostic comparative study.

The use of dry needling vs. corticosteroid injection to treat lateral epicondylitis: a prospective, randomized, controlled study.

BACKGROUND: Lateral epicondylitis (LE) is a common disease especially at middle age. Different types of treatments have been used to address LE. Corticosteroid (CS) injections and dry needling (DN) are utilized options in the treatment. However, the question of which one is better has not been entirely discussed in the literature. We hypothesized that the use of DN to treat LE would be at least as effective as using CS injections. We compared the pain relief afforded and improvements in functional disability after DN and CS injection. METHODS: A total of 108 LE patients whose pain was not relieved by 3 weeks of first-line treatment were included in a randomized manner, using an online application into DN or CS groups (54 patients each). The minimum follow-up duration was 6 months. We recorded "Patient-Rated Tennis Elbow Evaluation" (PRTEE) scores before treatment and after 3 weeks and 6 months of treatment. RESULTS: Seven patients were excluded for various reasons; thus, 101 patients were finally evaluated. Before treatment, the groups were similar in terms of age, symptom duration, and PRTEE score, but after treatment, DN-treated patients showed better improvement in the PRTEE score than CS-treated patients (P < .01). Both treatments were effective (both P < .01). From assessments at 3 weeks and 6 months post-treatment, PRTEE scores decreased over time. Four CS-treated patients (7.6%) developed skin atrophy and whitening. One DN-treated patient (2.04%) could not tolerate the pain of the intervention and withdrew from treatment. CONCLUSION: DN and CS injection afforded significant improvements during the 6 months of follow-up. However, compared with CS injection, DN was more effective.

The Use of Twisting and Tightening Tool to Strengthen the Cerclage and Tension Band Wiring.

Cerclage and tension band wiring are being used in most bone surgeries in different disciplines. The regularity of the twist on the node of a cerclage and tension band is thought to determine cerclage stability. For this purpose, a novel twisting and tightening tool was designed. This tool maintains extremely regular twists on the node, which we consider to be important for stability. In the present biomechanical trial, we aimed to investigate the consistency of the twists forming the cerclage node. This study was performed on a total of 30 cerclage loops. In group A (n = 15), the cerclage wire was tightened manually by a clipper, while in group B (n = 15), it was tightened using the twisting and tightening tool. In biomechanical tests, the cerclage loops were pulled apart by 2 hooks connected to the biomechanical device. The velocity was adjusted to 20 mm/min. On statistical analysis, there was a significant difference in the ultimate strength (P = .03) and the mean tensile strength (P = .01) between groups A and B. It was found that the strength of the cerclage wire can be increased by maintaining more regular twists. The twisting and tightening tool is a reasonable and useful device for both clinical and experimental usages.

EFAS Score - validation of Finnish and Turkish versions by the Score Committee of the European Foot and Ankle Society (EFAS).

BACKGROUND: The Score Committee of the European Foot and Ankle Society (EFAS) developed, validated, and published the EFAS Score in seven European languages (English, German, French, Italian, Polish, Dutch, Swedish). From other languages under validation, the Finnish and Turkish versions finished data acquisition and underwent further validation. METHODS: The EFAS Score was developed and validated in three stages: 1) item (question) identification (completed during initial validation study), 2) item reduction and scale exploration (completed during initial validation study), 3) confirmatory analyses and responsiveness of Finnish and Turkish version (completed during initial validation study in seven other languages). The data were collected pre-operatively and post-operatively at a minimum follow-up of 3 months and mean follow-up of 6 months. Item reduction, scale exploration, confirmatory analyses and responsiveness were executed using classical test theory and item response theory. RESULTS: The internal consistency of the scale was confirmed in the Finnish and Turkish versions (Cronbach's Alpha >0.8). Responsiveness was good, with moderate to large effect sizes in both languages, and evidence of a statistically significant positive association between the EFAS Score and patient-reported improvement. CONCLUSIONS: The Finnish and Turkish EFAS Score versions were successfully validated in the orthopaedic ankle and foot surgery patients, including a wide variety of foot and ankle pathologies. All score versions are freely available at www.efas.co.

Preliminary Report on the Role of Dry Needling Versus Corticosteroid Injection, an Effective Treatment Method for Plantar Fasciitis: A Randomized Controlled Trial.

Plantar fasciopathy (PF) is a common disorder for which there is no consensus regarding an optimal treatment strategy. We hypothesized that dry needling would be as effective as the use of corticosteroid injections for treating PF while avoiding the potential adverse effects of corticosteroids. After approval was received from the institutional review board, patients diagnosed with PF were prescribed a 3-week nonoperative treatment regimen. In addition to using oral and topical antiinflammatory drugs, patients engaged in plantar fascia and gastrocnemius stretching exercises. A study population of 98 patients was planned. An appointment was made in the third week of first-line treatment. Patients whose pain did not abate and who required further treatment were included in the study. One week later, we randomly divided patients into 2 groups using an online random number generator. Group 1 underwent dry needling, and group 2 underwent corticosteroid injection. All dry needling was performed by a single physiotherapist, and all corticosteroid injections were performed by the second author. Patients were assessed in the third week and sixth month by a single investigator using the foot function index. In terms of foot function index scores, dry needling caused significant decrease in the third week and also in the sixth month. However, although corticosteroid use led to a significant decrease at the third week, it lost efficacy in the sixth month (p < .001). In conclusion, dry needling seems to be a reliable procedure for treating PF, with better outcomes than corticosteroid injection.

Dry needling in lateral epicondylitis: a prospective controlled study.

PURPOSE: Lateral epicondylitis (LE), a common disease, especially in middle age, causes decreased productivity and economic losses. The first-line treatment for LE is conservative and consists of topical and oral anti-inflammatory drugs, ice application, and brace use. If the first-line treatment fails, second-line treatment modalities, which are generally invasive, are offered. Second-line therapeutic regimens include saline, corticosteroid, or platelet-rich plasma injections. Dry needling is relatively new. We hypothesized that dry needling would be at least as effective as first-line treatment for LE. We compared the outcomes of first-line treatment and dry needling. METHODS: The study allocated 110 patients into groups using online randomization software. After completing the Patient-rated Tennis Elbow Evaluation (PRTEE), patients in group I received dry needling, whereas those in group II received first-line treatment, consisting of ibuprofen 100 mg twice a day and a proximal forearm brace. The patients were evaluated after three weeks and six months. RESULTS: The study ultimately analyzed 92 patients. Although both treatment methods were effective at three weeks, dry needling was significantly more effective than the first-line treatment at six months. CONCLUSION: Because of the low complication rate, dry needling is a safe method, and it might be an effective treatment option for LE.

Ultrasound Guided Multisite Injection Technique in the Treatment of Frozen Shoulder.

Frozen shoulder (FS) is an elusive condition that affects patients' mental and emotional quality of their lives. Corticosteroid injection technique is one of the first-line treatment methods in the treatment of FS. Ultrasound (USG) guidance allows visualization of the shoulder anatomy and improves the accuracy of the injection site. This study describes an USG-guided injection technique for FS treatment. The aim of this technique was to affect glenohumeral joint and capsule, subacromial space, the long head of biceps tendon sheath, and the coracohumeral ligament. For this purpose, four different sites were injected by USG guidance. Patients with FS can be effectively treated through this technique that is detailed in this article.

Osteochondral Lesions of the Talus May Cause the Vacuum Phenomenon in the Ankle Joint.

The few reports available on the vacuum phenomenon in the ankle joint refer to osteoarthritic and traumatic lesions. We present the first case concomitant with an osteochondral lesion of the talus. This case report presents computed tomographic images of the ankle. We speculate that the osteochondral lesion of the talus was the most likely cause of the vacuum phenomenon.

The Two-Component Implant for Interphalangeal Fusion in Toe Deformities.

BACKGROUND: Although Kirschner wire implantation is popular for treating toe deformities, complications frequently occur. To prevent pin-tract infection and difficult Kirschner wire extraction, several implants have been developed to improve treatment outcomes. METHODS: Patients who had undergone an interphalangeal fusion by two-component implant for the treatment of toe deformities were included. Thirty-one toes of 21 patients were evaluated retrospectively. American Orthopaedic Foot and Ankle Society (AOFAS) forefoot scores were used in clinical evaluation. RESULTS: The mean operation duration per toe was 16.4 min (range, 13-26 min). The average AOFAS forefoot score was 42.76 (range, 23-57) preoperatively and 88.76 (range, 70-95) at 34.4 months (range, 26-46 months) after surgery. Mean follow-up was 14.8 months (range, 12-19 months). Compared with before surgery, the AOFAS score was increased significantly after surgery (P = .03 by t test). Three minor complications were encountered. In one patient an infection was observed. After the implants were removed (first month) she was treated successfully by debridement and antibiotic agents and, finally, Kirschner wire placement. The second patient had a fissure fracture at the proximal phalanx, but routine follow-up did not change. In the third patient, the locking mechanism had become loose (detected on day 1 radiography); it was remounted under fluoroscopy without opening the wound. No patients had a cutout, loss of alignment, recurrence, or persistent swelling. CONCLUSIONS: Outcomes of arthrodesis using the two-component implant were found to be safe and reliable, especially for hammer toe and fifth toe deformities.

Effectiveness of distally slotted proximal femoral nails on prevention of femur fractures during and after intertrochanteric femur fracture surgery.

INTRODUCTION: Intra- and post-operative femoral shaft fractures related with nailing remain of concern. Although manufacturers have sought to solve the problem by providing distally slotted nails, it is not clear that these implants reduce fractures. We compare two distally slotted proximal femoral nails [trochanteric nail (TRON) and proximal femur intramedullary nail (PROFIN)]. PATIENTS AND METHODS: The medical records of 195 hips treated with TRONs (distally slotted in four places in the sagittal and coronal planes) and 583 hips treated with PROFINs (distally slotted in two places in the coronal plane) in two institutes were retrospectively evaluated. The inclusion criteria were follow-up for at least 6 months; pertrochanteric fractures and age over 55 years. RESULTS: In total, 161 hips in the TRON group and 512 hips in the PROFIN group were included. The mean follow-up time was 28.5 (range: 6-84) months in whole group. The demographic characteristics of the groups were similar. Only 2 intraoperative shaft and 3 proximal lateral cortex fracture was detected in PROFIN group, there wasn't any postoperative fracture. Four proximal lateral cortex and 2 femur shaft fractures were detected in TRON group (one during operation and one at postoperative 8th month after a fall at pedestrian way). CONCLUSIONS: Distal cephalomedullary nail slotting prevented intra- and post-operative femoral fractures. A distal slot 50 mm in length may increase nail elasticity and reduce nail tip stress to a greater extent than a 30-mm slot. Distal slotting in both the sagittal and coronal planes afforded no advantage compared to coronal slotting only. LEVEL OF EVIDENCE: Level III retrospective study.

Which Emerges First: Bone Marrow Edema or Nidus in Osteoid Osteoma?

This case report describes a well-documented birth and evolution of an osteoid osteoma at the talus. Although initial radiologic images indicate mild bone marrow edema at first (without nidus), subsequent magnetic resonance imaging and computed tomographic images reveal pathognomonic nidus at the talus. During the evolution of the lesion, typical night pain was coincident with the occurrence of the nidus, as seen on magnetic resonance imaging. This may be interpreted that nidus formation may be related to the night pain. In this report, the first finding was bone marrow edema. Although our classic knowledge was that the edema follows the lesion, this report makes a difference. The relationship between bone marrow edema and osteoid osteoma has not been questioned in the literature before. We speculate that this report brings to mind, the question of which comes first? A bone marrow edema or nidus? Another question is: Does osteoid osteoma always start with such a dust cloud in the bone as we presented herein?

An unusual presentation of Trevor's disease at the ankle joint: Involvement of both medial and lateral epiphyses.

INTRODUCTION: Trevor's disease, also known as dyplasia epiphysealis hemimelica, is characterised by osteochondromas arising from epiphyses. The disease typically affects one side of an epiphysis (usually the medial side). CASE PRESENTATION: A case in whom both the medial and lateral sides of the epiphysis were involved is described. Thus, the use of the descriptor "hemimelica" is not always appropriate. CONCLUSION: Although rare, Trevor's disease should be kept in mind during the differential diagnosis of patients with ankle pain and a mass. Other possible joints should be examined to explore multiple involvement. Surgical treatment, only on lesions causing impingements, may improve functional status and reduce pain.

Medial malleolus fractures: A biomechanical comparison of tension band wiring fixation methods.

BACKGROUND: This study compared the biomechanical properties of three different fixation methods of tension band wirings, used in the treatment of medial malleolus fractures. The first method used an innovative "handmade bent pin" for cerclage fixation. The second method used a U-shaped K-wire to attach the cerclage to the medial tibial cortex. These two novel fixation techniques were compared with the traditional tension band wiring technique which is fixated to the bone by a screw. HYPOTHESIS: Novel fixation techniques of tension band wiring provide stable fixation. MATERIAL AND METHODS: In this study 27 artificial bone models, which medial malleolus fractures were simulated on, were used. Using an electromechanical test device, the force required to pull out each implant was assessed and compared. RESULTS: This study found that; while handmade bent pinning resulted averagely 840.25N (range: 647-1066±118.72) and U-shaped K-wire fixation was 381.71N (range: 176-651±150.2) pull out strength, traditional tension band wiring indicated 871.33N (range: 549-1008±137.74) pull out strength. DISCUSSION: Handmade bent pinning method provide similar results with traditional tension band wiring. Therefore, in suitable cases, it may be an acceptable alternative to traditional tension band wiring techniques when treating malleolar fractures. Although the outcomes of U-shaped K-wire fixation indicated lower than other two groups, the outcomes were comparable with the literature. So while performing tension band wiring, both handmade fixation systems may be used in certain cases. For Orthopaedic surgeons, it is better to know and think about these alternative handmade pinning systems created from simple K-wires during the surgery if needed. LEVEL OF EVIDENCE: IV, Biomechanical trial.

Radiological and clinical outcomes of medial approach open reduction by using two intervals in developmental dysplasia of the hip.

OBJECTIVE: To evaluate the midterm clinical and radiological outcomes of the medial approach using two intervals for developmental hip dysplasia (DDH). METHODS: The study involved 62 hips of 47 patients (41 girls, 6 boys) treated with medial approach for DDH from 1999 to 2010. The age of the patients at surgery was 18.7 ± 2.25 months. Follow up of the patients was 11.3 ± 3.07 years. The age of the patients at the last follow up was 12.6 ± 1.74 years. According to the Tönnis classification, 13 hips were grade II, 27 hips were grade III and 22 hips were grade IV. Patients were evaluated according to Omeroglu radiological criteria and modified McKay functional criteria. The presence of avascular necrosis (AVN) of the hip was questioned using the KalamchiMacEwen classification. RESULTS: Radiologically, forty eight (77%) hips were evaluated as "excellent", 8 (13%) hips as "good" and 5 (8%) hips as "fair plus" and 1 (%2) hip as "fair minus". Two (3%) patients had type 1 temporary AVN and one (1%) patient had type 4 AVN with coxa magna and overgrowth of the greater trochanter. According to McKay functional criteria, 56 (90%) hips had "excellent" and 6 (10%) had "good" results. Two (3.2%) hips of one patient had to be reoperated with Salter osteotomy and femoral shortening + derotation osteotomy. CONCLUSION: Medial approach using two separate intervals for tenotomy and capsulotomy does not jeopardize the medial circumflex or the femoral vessels and yields satisfactory midterm results for children 18 months old with dysplasia of the hip. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Can washing socks without flipping inside out cause hair tourniquet syndrome? A claim with two case reports.

Hair tourniquet syndrome (HTS) is a rare, painful condition that results when hair or pieces of thread become wrapped tightly around toes, fingers, or other appendages, occluding blood flow and causing strangulation or amputation. Although the aetiology of HTS is unclear, we postulate that washing baby socks in a washing machine without turning them inside out might be a cause. Mothers should be informed about HTS and this simple prevention method should be suggested to them. Here, we present two cases of HTS and discuss possible causes.

Factors predicting the outcomes of incomplete triple pelvic osteotomy.

INTRODUCTION: In the present study, we identified factors affecting the outcomes of patients who underwent incomplete triple pelvic osteotomies due to acetabular dysplasia. METHODS: Data on a total of 58 hips in 50 patients for whom adequate data were available and who had undergone appropriate follow-up were retrospectively evaluated. We used Ömeroglu scores for radiological evaluation, Harris Hip Scores for clinical evaluation, Tönnis scores to evaluate osteoarthritis progression and a modified Clavien-Dindo classification to evaluate complications. RESULTS: The average patient age was 23.26 (14-47) years, and the average follow-up duration 105.59 (18-191) months. The complication rate was 10.3%, and complications negatively influenced clinical outcomes. Patients with radiologically poorer outcomes had more advanced osteoarthritis. We found minimal improvements in lateral centre edge angle (LCEA), refined centre-edge angle (RCEA), and lateral acetabulum head index (LAHI) were associated with osteoarthritis progression and that good improvements in LCEA, RCEA, acetabular angle (AA), and LAHI were associated with radiological outcomes. Neither patient age at the time of operation nor development of a postoperative relative crossover sign affected osteoarthritis progression or clinical or radiological outcomes. CONCLUSIONS: The most important factors influencing clinical outcomes were complications. However, neither postoperative acetabular retroversion nor a positive supra-equatorial crossover sign (often viewed as prognostically negative) directly affected clinical outcomes.When treating patients with acetabular dysplasia, either inadequate correction or overcorrection may negatively affect outcomes. In such patients, an incomplete triple pelvic osteotomy (allowing controlled correction) is both safe and effective.

A comparison of Chevron and Lindgren-Turan osteotomy techniques in hallux valgus surgery: a prospective randomized controlled study.

OBJECTIVE: The aim of this prospective randomized controlled single-blind study was to compare the results of Chevron and Lindgren-Turan osteotomy techniques for treatment of moderate hallux valgus. METHODS: A total of 66 female patients (34 in Chevron group, 32 Lindgren-Turan group) were recruited in this study and followed up for an average of 26.08 months. Operative procedures were performed by 2 surgeons, and patients were evaluated by an another researcher who was blinded to the surgical technique. The groups were compared for their radiological and clinical results. RESULTS: Both techniques was clinically and radiologically effective (p<0.01). However, no significant differences were found between the 2 groups regarding American Orthopaedic Foot and Ankle Society's clinical rating system, Painful Foot Evaluation scale of Maryland University scores, or radiologic evaluation (p>0.05). Compared to the Chevron group, the Lindgren-Turan group was found to have shorter surgical duration (p<0.05) and significantly more shortening at the first metatarsal (p<0.05). CONCLUSION: In moderate hallux valgus deformity, both the Chevron and Lindgren-Turan osteotomy techniques are clinically and radiologically safe, effective, and reliable alternatives. No superiority was detected in either technique. Although shortening at the first metatarsal in the Lindgren-Turan group was radiologically significant, the results were clinically tolerable.

A new and simple suturing technique applied after surgery to correct ingrown toenails may improve clinical outcomes: A randomized controlled trial.

INTRODUCTION: In the present study, we investigated the efficacy of a new suturing technique applied after the Winograd procedure has been completed. METHODS: This study was prospective, randomized, and controlled. In total, 128 patients were recruited and divided into two groups. The outcomes of those treated with the new suturing technique (group I) were compared with those of patients treated with the traditional suturing technique (group II), both of which were applied after the Winograd procedure had been completed. The clinical outcomes and recurrence rates of the two groups were compared. RESULTS: Patients in group I required significantly more time to return to work or school than did those in group II (p = 0.015). We found no significant difference between youths (age < 18 years, n = 55) and adults (age ≥ 19 years, n = 69) in this context (p = 0.161). The recurrence rate was significantly higher in group II than in group I (p = 0.011). The extent of satisfaction was significantly higher in group I (p = 0.042). CONCLUSIONS: Our new suturing technique is associated with lower recurrence and higher satisfaction rates. However, the times elapsing before shoes could be worn were similar in the two groups.

Precise placement of lag screws in operative treatment of trochanteric femoral fractures with a new guide system.

PURPOSE: We assessed the accuracy of a new guide system that we developed to place lag screws in the proper position with the minimum number of attempts for operative treatment of trochanteric femoral fractures. METHODS: A total of 55 consecutive trochanteric femoral fractures were treated with a cephalomedullary nail. The first 27 consecutive patients were treated with the standard operation (group A), while the new guide system was used in the last 28 consecutive patients (group B). The numbers of attempts to place K wires and the duration of surgery were noted. Accuracy of lag screw placement was evaluated by measuring the angle of deviation from the central axis of the femoral head. RESULTS: Deviation values ranged from -11̊ to +15̊ for the 27 cases in group A, with a median absolute deviation of 8̊±6̊. That in the 28 cases after the introduction of the new guide system (group B) ranged from -5̊ to +6̊, with a median absolute deviation of 0.5̊±3̊ (P<0.001). The total numbers of attempts to place lag screws and mean operation time decreased significantly after introduction of the new guide system (P<0.001). CONCLUSIONS: With this new guide system, we are able to insert lag screws successfully in the optimal position even in most unstable fractures. The present study indicated that this new guide system and nail facilitate accurate placement of lag screws in the appropriate position with the minimum number of attempts.