Platelet-rich plasma in the management of rotator cuff tendinopathy.

Platelet-rich plasma (PRP) is an autologous blood-derived product that has gained significant attention in the treatment of tendinopathies as one of many treatment modalities in the field of regenerative medicine. Rotator cuff pathologies are the leading cause of shoulder pain. Despite the high success rate with conservative treatment and arthroscopic surgical repair, the search for a nonsurgical treatment has made PRP a trending topic recently. The purpose of this article is to review the recent literature data on the possible role of PRP in different rotator cuff pathologies. The limited data in the literature about isolated tendinopathies without a tear (tendonitis and tendinosis) suggests potential benefit from conservative treatment with PRP. Many studies exist for the treatment of rotator cuff tears solely using PRP or as an augmentation to arthroscopic repair. Despite the large number of randomized clinical trials and meta-analyses about the topic, there is no consensus in favor of routine application of PRP in this patient population. The existing reliable evidence of benefit seems to be restricted to its use in only inflammatory tendinopathies with preserved tendon integrity.

Does the Surgical Approach Influence Bleeding in Hip Fracture Patients Taking Clopidogrel?

Background The aim of this study was to evaluate the effect of the choice of approach on bleeding in patients with femoral neck fractures who are on clopidogrel. Materials and methods The study included patients over the age of 60 who were taking clopidogrel and had hemiarthroplasty surgery for a femoral neck fracture. A total number of 61 patients were evaluated in the study. Patients who underwent surgery using the posterior approach were assigned to group 1, while those who underwent surgery using the anterolateral approach were assigned to group 2. Preoperative and postoperative hemoglobin levels, transfusion needs, red blood cell (RBC) loss, duration of surgery, and the length of hospitalization were evaluated. Results The mean age of the patients was 79.36 ± 7.72 years. Twenty-nine patients were included in group 1 and 32 patients were included in group 2. There was no significant difference between the two groups in terms of gender, age, and comorbidities (p=0.74, p=0.12, p=0.23, respectively). There were no significant differences between group 1 and group 2 in terms of duration of surgery and length of hospital stay (p=0.41, p=0.37, respectively). Also, there was no significant difference in RBC loss between group 1 and group 2 (p=0.37). Conclusion The use of anterolateral or posterior approaches has no effect on bleeding in clopidogrel-treated patients having hemiarthroplasty for femoral neck fracture. The authors recommend surgeons choose the approach according to their experience and patients' needs.

A brief introduction to medical image processing, designing and 3D printing for orthopedic surgeons.

Advancements in technology and the industry have changed the way that physicians deliver healthcare to their patients. Orthopedic surgery is one of the medical fields chasing advancing technology closely and making it a part of routine practice quickly. Patient-centric approach and customization of the care according to patient's needs are the key components in this new concept. Customized surgical planning with three-dimensional (3D) modelling and printing of the anatomy of each patient scheduled for surgery, custom made implants are on their ways to become the standard of the care. As a result, a higher proportion of technical personnel than before is expected to be involved in the healthcare. Orthopedic surgeons need to be familiar with this new working model and technical terminology to be able to communicate with the technical members of healthcare thoroughly. Processing of the medical images, computer-aided design (CAD) programs and 3D printing are the crucial parts of this workflow. In this review, we discuss the basics concepts of these components with the examples from 3D Slicer as a medical image processing platform and Shapr3D as a CAD platform, with the aspect of orthopedic surgeons.

Systematic triage and treatment of earthquake victims: Our experience in a tertiary hospital after the 2023 Kahramanmaras earthquake.

OBJECTIVES: The aim of this study was to evaluate the benefits of our triage system in acceleration of intervention for the musculoskeletal injuries and clinical follow-ups of trauma patients admitted to our center after the Kahramanmaras earthquake. PATIENTS AND METHODS: Between February 6th, 2023 and February 20th, 2023, a total of 439 patients (207 males, 232 females; mean age: 37.1±19.1 years; range, 1 to 94 years) with earthquake-related musculoskeletal injuries after the Kahramanmaras earthquake were retrospectively analyzed. Data including age, sex, referral city information, removal time from the rubbles, physical examination findings, clinical photos, fasciotomy and amputation stumps and levels, and X-ray images and computed tomography images of all patients were shared and archived in the WhatsApp (Meta Platforms, Inc.® ATTN/CA, USA) group called 'Earthquake' created by orthopedic surgeons. To complete the patient interventions as soon as possible and to ensure order, the patients were distributed with the teams in order through this group by the consultant orthopedic surgeon. The treatments were applied and recorded according to the skin and soft tissue conditions, and fractures of the patients. All treatments were carried out with a multi-disciplinary approach. RESULTS: Of the patients, 16.2% were children. Lower limb injuries constituted 59.07% of musculoskeletal injuries. Upper limb, pelvic, and spinal cord injuries were observed in 21.9%, 12.7%, and 6.25%, respectively. Conservative treatment was applied to 183 (41.68%) patients. The most common surgical intervention was debridement (n=136, 53.1%). External fixation was applied in the first stage to 21 (8.2%) patients with open fractures. The mean removal time from the rubbles was 32.1±29.38 h. A total of 118 limb fasciotomy operations were applied to the patients. Fifty limb amputations were performed in 40 patients at the last follow-up due to vascular insufficiency and infection. CONCLUSION: Based on our study results, we believe that a triage system using a good communication and organization strategy is beneficial to prevent treatment delay and possible adverse events in future disasters.

Preventing extremity amputations after earthquakes: a quantitative analysis of fasciotomy and extrication time.

PURPOSE: The purpose of this study is to evaluate the impact of prolonged extrication time and the time to fasciotomy applications on amputation requirement by giving quantitative and cutoff values. METHODS: In this single-center study, the clinical records of patients with musculoskeletal injuries due to the 6 February Kahramanmaras earthquake in Turkey were retrospectively reviewed. All patients who underwent fasciotomy or amputation regardless of age and gender were included in the study. 163 extremities of 140 patients who met the inclusion criteria were evaluated. Demographic data of the patients, such as age and gender, were recorded in this study. The primary outcome of this study was the correlation of the time between injury and fasciotomy applications with the amputation requirement. At the same time, the effect of prolonged extrication time of earthquake victims on amputation requirement. RESULTS: The mean age was 29.01 ± 15.55 of earthquake victims included in the current study and the gender distribution of the patients is almost equal. 87 amputations of 65 patients were performed and transtibial amputation was the most common type (41.3%). The mean fasciotomy time was 38.78 ± 23.64 h. Delayed fasciotomies performed after 45.5 h increase 28.48 times the amputation requirement. The mean extrication time in the current study was 36.49 h. The patients with extrication time longer than 23 h was associated with an 8.8 times higher risk of amputation. CONCLUSIONS: Authors believe that knowledge of the relationship between earthquake survivors' prognosis and time of extrication, as well as the impact of fasciotomy timing on extremity loss, is essential for a more successful treatment management in future disasters.

A Safe Technique to Ensure Not to Unload a Suture Anchor: Suture Dyeing.

Suture anchors are frequently used in shoulder arthroscopy. After suture anchors are inserted into bone, the suture transfer between portals should be performed carefully. Sometimes, as a result of the transfer of the wrong suture limb, the suture anchor may be unloaded. The suture dyeing technique provides secure suture retrieval between portals.

Capsular remnant in the rotator cuff footprint is a novel arthroscopic finding may indicate the etiology of the tear.

PURPOSE: The aim of the study was that the capsule remnant is a common indicator of sub-acromial impingement syndrome and bursal side onset rotator cuff tears. METHODS: Sixty-three patients with capsule remnants in the rotator cuff footprint (Study group) were detected, while the 53 patients did not have any remnant on the tendon footprint (Control group) between 2015 and 2020 were included. Demographic data of patients, such as age, gender, and operated side information were obtained from the archive files. Acromion type, presence of osteophytes in the acromioclavicular joint, Acromiohumeral Distance (AHD), Acromial Index (AI), Critical Shoulder Angle (CSA), and Coracoacromial Ligament (CAL) degeneration values were evaluated from preoperative MRI, radiographic images, and arthroscopic video recordings. RESULTS: Severe stages of CAL degeneration were observed in 82.5% of the patients who had capsule remnant (p: 0.001). While type 2 acromion was found in 61.9%, and also acromioclavicular joint osteophyte was found in 58.7% of the patients in the study group. The mean AHD was 8.22 ± 1.56 mm in the study group and 9.2 ± 1.3 mm in the control group. The mean CSA was 43.3 ± 4.9 in the study group and 40.8 ± 4.2 in the control group. The AI was measured as 0.8 ± 0.1 in the study group and 0.8 ± 0.01 in the control group. As a result of these measurements, a statistical difference was found between the two groups in terms of type 2 acromion ratio (p < 0.001), presence of osteophytes in the acromioclavicular joint (p < 0.001), mean acromio-humeral distance (p < 0.001), critical shoulder angle (p = 0.004), and acromial index values (p < 0.001). CONCLUSION: The findings of sub-acromial impingement syndrome were found to be more prominent in patients with full-thickness degenerative tear and findings of capsular remnant in the footprint. If the presence of the current finding is detected during glenohumeral arthroscopy, sub-acromial impingement syndrome should be examined in more detail to reveal the underlying cause and prevent a recurrence.

Evaluation of the anterior shoulder instability using ultrasound shear wave elastography.

OBJECTIVES: This study aims to evaluate the soft tissue stiffness which has a prominent role in shoulder instability using ultrasound (US) shear wave elastography (SWE) and to compare the results with healthy shoulders. PATIENTS AND METHODS: Between December 2018 and January 2020, a total of 33 male patients (mean age: 26±4.3 years; range, 18 to 35 years) who underwent arthroscopic repair for traumatic isolated anterior glenohumeral instability were included in this prospective study. The shoulder girdle was evaluated with US SWE in patients with traumatic anterior instability. Deltoid (D), supraspinatus (SS), infraspinatus (IS), subscapularis (SSC), and long head of biceps (LHB) tendons forming the shoulder girdle and anterior labrum (L) were evaluated with SWE. The elasticity and velocity of the tissues were quantitatively measured. The operated shoulders of 33 patients due to isolated traumatic anterior instability were named Group 1, while the healthy shoulders of these patients were named Group 2. Thirty volunteers with healthy shoulders were considered as the control group (Group 3, n=30). RESULTS: All three groups were compared in terms of SS, D, LHB, and SSC tendon velocity and elasticity; however, no statistically significant difference was observed among the groups (p<0.05). The anterior labrum of these three groups did not significantly differ in terms of SWE measurements (p<0.05). CONCLUSION: The stiffness of shoulder girdle muscle tendons and labrum measured with US SWE does not constitute a risk factor for traumatic anterior shoulder instability.

Can subcoracoid effusion be a more specific finding for subscapularis tear among rotator cuff pathologies on magnetic resonance imaging?

HYPOTHESIS AND BACKGROUND: Magnetic resonance imaging (MRI) is a well-known, noninvasive diagnostic method for rotator cuff tendon pathologies that are not very sensitive for subscapularis tendon tears. Subcoracoid effusion (SE) is an easily recognizable radiologic sign on MRI. In this study, we aimed to examine the relationship of SE with rotator cuff tear and to investigate whether SE could be a supportive finding in the diagnosis of subscapularis tear in preoperative MRI. Our hypothesis was that SE was a more specific finding of subscapularis tear than other rotator cuff tears. METHODS: The data of patients who underwent shoulder arthroscopy in our clinic between 2017 and 2021 were analyzed retrospectively. Four groups were included in the study: patients with a rotator cuff tear accompanied by a subscapularis tear (group 1, n = 273), patients with isolated subscapularis tear (group 2, n = 57), patients with rotator cuff tear with intact subscapularis tendon (group 3, n = 190), and patients without any rotator cuff pathology (group 4, n = 263). Arthroscopic video records and MRIs of all patients were evaluated retrospectively. Subscapularis tendon tears were classified according to the Lafosse classification. RESULTS: There was a statistically significant difference between the groups in terms of the presence of SE on MRI (P = .001). The presence of SE in group 1 and group 2 was statistically significantly higher than that in both group 3 and group 4 (P = .001), and there was no significant difference between group 3 and group 4 (P > .05). A significant relationship was found between Lafosse classification and SE (P = .001). When the diagnostic powers of the detection of SSC tear and the presence of SE on MRI for SSC tear were compared, Kappa values were 0.615 (P = .001) and 0.701 (P = .001), and overall diagnostic accuracy rates were 80.3% and 85.5%, respectively. CONCLUSION: We conclude that SE is a more specific finding for subscapularis tears than other rotator cuff pathologies. We suggest that SE on MRI should also be considered in patients with a rotator cuff tear in whom a subscapularis tear was not detected in preoperative MRI and that the subscapularis tendon should be carefully evaluated during surgery in cases where the effusion is positive.

Pain relief and functional improvement provided by extracorporeal shock wave therapy in plantar fasciitis is better than corticosteroid injection and kinesio taping: A randomized trial.

Objectives: This study aimed to evaluate the results of extracorporeal shock wave therapy (ESWT), corticosteroid injection (CI), and kinesio taping (KT) in terms of pain and function in plantar fasciitis (PF). Patients and methods: In this prospective study, 90 feet of 64 patients (11 males, 53 females; mean age: 38.3±10.4 years; range, 22 to 70 years) who presented with chronic PF between November 2021 and March 2022 were evaluated. The patients were randomized to three groups, with 30 feet in each group: the CI group, the ESWT group, and the KT group. Each group received only the respective treatment modalities assigned to their group. Pain assessment of the patients before the treatment and at six weeks, three months, and six months was evaluated with the Visual Analog Scale (VAS), and their functions were evaluated with the American Orthopedic Foot and Ankle Society (AOFAS) score. Results: There was no statistical difference in the demographic data (age, body mass index, and VAS; all p>0.05). At six weeks, VAS was statistically significantly lower in the CI group compared to the other groups (p<0.001), but there was no difference in AOFAS between the groups (p=0.666). At three months, there was no statistical difference between the groups regarding VAS (p=0.311), while the AOFAS was higher in the ESWT group (p=0.006). At six months, VAS was lower (p<0.001) and AOFAS was higher (p=0.003) in the ESWT group. Conclusion: All three commonly used treatment modalities, ESWT, CI, and KT, are effective in reducing pain and increasing function in chronic PF. However, while CIs can be more effective in relieving pain in the early period, the most significant improvement at the end of the sixth month was achieved by ESWT.

Evaluation of oxidative stress in degenerative rotator cuff tears.

BACKGROUND: Oxidative stress occurs as a result of the disruption of the balance between the formations of reactive oxygen species and antioxidant defense mechanisms during the conversion of nutrients into energy. Increased body oxidative stress has been reported to be involved in the etiology of several degenerative and chronic diseases. We hypothesized that the body oxidative stress level is higher in patients with atraumatic degenerative rotator cuff tear than that in healthy individuals. METHODS: The patients who underwent arthroscopic repair for atraumatic, degenerative rotator cuff tear were prospectively evaluated. A total of 30 patients (group 1, 19 females and 11 males; mean age: 57.33 ± 6.96 years; range: 50-77 years) and 30 healthy individuals (group 2, 18 females and 12 males; mean age: 56.77 ± 6 years; range: 51-72 years) were included in the study. The Constant and American Shoulder and Elbow Surgeons scoring systems were used to evaluate the clinical outcomes. Serum oxidative stress parameters of the patients and the control group were biochemically evaluated. Accordingly, thiol/disulfide (DS) balance (DS/native thiol [NT], DS/total thiol [TT]), Total Oxidant Status (TOS), oxidative stress index, and nuclear factor erythroid-2-associated factor-2 values were used as the biochemical parameters indicating an increase in the serum oxidative stress level. Total antioxidant status and NT/TT values served as the biochemical parameters indicating a decrease in the serum oxidative stress level. RESULTS: The study follow-up duration was 12 months. A statistically significant increase was observed in American Shoulder and Elbow Surgeons and Constant scores of patients who underwent arthroscopic rotator cuff repair relative to that during the preoperative period (P = .01). The values of biochemical parameters (DS/NT, DS/TT, TOS, oxidative stress index, and nuclear factor erythroid-2-associated factor-2), which indicated an increase in the serum oxidative stress, were significantly higher in preoperative patients than those in postoperative patients, albeit the control group values were significantly lower than those of the postoperative patients. The biochemical parameters (NT/TT and total antioxidant status) indicating a decrease in the serum oxidative stress levels were significantly higher in the postoperative patients than those in the preoperative patients and significantly lower than those in the control group. CONCLUSION: High levels of markers indicating an increase in the serum oxidative stress in patients with degenerative rotator cuff rupture suggested that TOS may be involved in the etiopathogenesis of rotator cuff degeneration. Although the oxidative load decreases during the postoperative period, the fact that it is still higher than that in healthy individuals supports this claim.

Evaluation of avascular necrosis risk factors after closed reduction for developmental dysplasia of the hip before walking age.

Avascular necrosis (AVN) of the femoral head is one of the most important complications after closed reduction and spica cast application in developmental dysplasia of the hip (DDH) treatment. This study aims to put forth the impact of closed reduction age and other factors which can cause AVN. Inclusion criteria of the study were: closed reduction and spica cast application before walking age (12 months) and minimum 2 years duration of follow-up. The presence of femoral head ossific nucleus, International Hip Dysplasia Institute (IHDI) score, acetabular indices and AVN were evaluated from radiographies. Hip abduction angles were evaluated on CT images. The absence of the ossific nucleus at the closed reduction time and preoperative IHDI grade were not significant risk factors for AVN (respectively OR = 2.83; 95% CI, 0.99-8.07; P = 0.052; OR = 2.5; 95% CI, 0.85-7.32; P = 0.094). For the patients older than 10 months, (1) the absence of the ossific nucleus was a significant risk factor for grade 2 or higher AVN according to the Bucholz Ogden criteria (P = 0.020) and (2) the higher preoperative IHDI grade (IHDI 3-4) was a significant risk factor for AVN (P = 0.032). AVN of the femoral head was a significant risk factor for fair or poor clinical outcome (P = 0.001). It is not reasonable to wait for radiological visibility of the ossific nucleus to prevent femoral head AVN before applying closed reduction and spica cast, irrespective of the age interval.

Predictivity of International Hip Dysplasia Institute classification in Pavlik harness treatment and correlation with Graf ultrasonographic classification.

Hip ultrasonography applied according to Graf's criteria is frequently used in early diagnosis and monitoring of developmental dysplasia of the hip (DDH). Recently, the International Hip Dysplasia Institute (IHDI) classification has been proposed to be a prognostic indicator for patients with walking-age DDH. The purpose of this study is to evaluate the reliability of IHDI classification in the follow-up of patients with DDH diagnosed by ultrasonography scanning. A total of 69 hips of 38 patients (10 men, 28 women; mean age 59.9 ± 19.8 days, range 29-90 days) were diagnosed with DDH younger than 90 days of age. The AP pelvis radiographs of the patients who were diagnosed with DDH by ultrasound and classified according to the Graf method were evaluated and classified according to IHDI classification. A total of 52 hips were treated successfully with Pavlik harness treatment, 15 hips underwent closed reduction and pelvipedal casting (PPC) and 2 hips underwent open reduction and PPC after failed Pavlik harness treatment. Increasing IHDI grades correlated with the failure of Pavlik harness treatment (P = 0.001). Graf classification was not found to be predictive of successful Pavlik harness treatment (P = 0.482). There was no significant correlation between the IHDI classification and the Graf classification (Kappa = 0.079 ± 0.102, P = 0.402). The IHDI method is reliable in predicting the success of Pavlik harness treatment in patients diagnosed with DDH using the Graf method.

Effects of developmental dysplasia of the hip screening program on the treatment strategies: A retrospective study from a tertiary care hospital in the southeast region of Turkey.

OBJECTIVE: The aim of this study was to investigate the effects of the developmental dysplasia of the hip screening program on the treatment procedures in a tertiary health care center. METHODS: We retrospectively reviewed all the DDH patients between 2012 and 2019 from the operating theatre records. The patients were separated based on the year of treatment. The rates of each treatment modality were determined respectively from 2012 to 2019, and Pavlik harness usage of the patients were queried. The changes in the rates of several surgical interventions after the start of screening program were identified. RESULTS: Between 2012 and 2019, 831 interventions were applied to 711 DDH patients. Closed Reduction (CR) is the least invasive treatment method, and it increased significantly from 20% to 46%. The rate of Open Reductions (OR) also increased from 3% to 9% at this time period, but it was statistically insignificant. Conversely, Pemberton-Salter Osteotomy (PSO) and Dega-Chiari Osteotomy (DCO) rates decreased significantly (41% to 28% and 9% to 0%, respectively). The rate of Pemberton- Salter osteotomy with femoral shortening (PSO-FS) rate decreased insignificantly from 27% to 20%. In patients that used Pavlik harness, the most common intervention was CR (83%). In CR group, the screened newborn rate increased more than two times from 2012 to 2019. CONCLUSION: The results of this study have shown that after the initiation of the screening program for DDH, less invasive treatment modalities such as CR and OR interventions increased, and major bony procedures such as PSO, PSO-FS and DCO interventions decreased. Furthermore, as the screening program advanced, CR rate and the use of Pavlik harness rate in CR interventions increased. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Patellar Fixation With Suspensory Fixation Device in Single-Tunnel Medial Patellofemoral Ligament Reconstruction.

The medial patellofemoral ligament (MPFL) is the primary soft-tissue stabilizer of the patellofemoral joint. Among the patellofemoral instability surgery options, MPFL reconstruction is the most preferred soft-tissue procedure. There is no gold-standard surgical treatment method in MPFL reconstruction, and many surgical methods have been described. We describe our surgical technique for MPFL reconstruction wherein the semitendinosus autograft is fixed to a single tunnel opened in the patella with a suspensory fixation device and only a single interference screw on the femoral side.

The Association Between BMP-2, UQCC1 and CX3CR1 Polymorphisms and the Risk of Developmental Dysplasia of the Hip.

OBJECTIVE: Developmental dysplasia of the hip (DDH) is a complicated skeletal disease ranging from subluxation to complete dislocation of the hip as a result of insufficient development of the acetabulum and femur. To date, numerous genes such as C-X3-C motif chemokine receptor 1 (CX3CR1), ubiquinol-cytochrome c reductase complex assembly factor 1 (UQCC1) and growth/differentiation factor 5 (GDF5), have been investigated to elucidate the underlying genetic etiology. Turkish population is one of the communities where DDH patients frequently observed, but almost no study has been conducted to elucidate the genetic etiology. In our study, we aimed to investigate the polymorphism of CX3CR1 rs3732378 and UQCC1 rs6060373, which have been shown to be associated with DDH in different populations. In addition, we aimed to investigate the BMP-2 rs235768 polymorphism which has not been investigated in the etiology of DDH. METHODS: Overall, 168 subjects (68 participants in the patient group, 100 participants in the control group) were investigated. The participants with following evidence and symptoms were excluded from the two groups: any systemic syndrome, another congenital anomaly, hereditary diseases, breech presentation, history of oligohydramnios, swaddling and high birth weight (> 4000 g). 3 single-nucleotide polymorphisms (SNP) were examined by qRT-PCR method. RESULTS: For CX3CR1 rs3732378 polymorphism, significant differences were observed in genotypes and allele frequencies (p < 0.0001). This condition was associated with a 12-fold increased risk in recessive modeling and 75-fold increased risk in dominant modeling. There was no significant relationship between DDH and the other two polymorphisms. CONCLUSIONS: Our work is the first study to investigate DDH and genetic polymorphisms in Turkish population where DDH is observed quite frequently. It is also the first study to investigate the relationship between BMP-2 rs235768 polymorphism and DDH. Our study revealed a clear relationship between CX3CR1 rs3732378 polymorphism and DDH in Turkish population.

Using the modified Ponseti method to treat complex clubfoot: Early results.

OBJECTIVES: This study aims to present the results of complex clubfoot patients treated with modified Ponseti method and put forth the warning clinical signs of complex deformities. PATIENTS AND METHODS: A total of 11 patients (10 males, 1 female; mean age 60.1±49.7; range, 2 to 180 days) with 16 complex clubfeet treated with modified Ponseti method were included in this study conducted between January 2016 and June 2019. All the data of the patients were collected prospectively and reviewed retrospectively. Demographic features, clubfoot severity, number of casts, position of each foot before cast removal, ankle dorsiflexion (DF), complications, and additional procedures were noted at all clinical visits. RESULTS: Eleven (11.2%) of 98 patients had complex clubfoot deformity. Six (7.7%) of 78 newly diagnosed patients and five (25%) of 20 referred patients had complex clubfeet. We treated 16 complex clubfeet of 11 patients. The mean follow-up period was 13.3 (range, 10 to 16) months. All deformities were initially corrected using a mean of seven (range, 5 to 8) casts and Achilles tenotomy. Relapses occurred in three (18.75%) patients, but all recovered after recasting. The creases above the heels disappeared in all of the patients, whereas plantar creases persisted on two (12.5%) feet. Pirani scores and DF improved statistically significantly after treatment, and DF improved significantly between tenotomy and the final visit. CONCLUSION: The modified Ponseti method is an effective treatment for complex clubfoot. Classical clinical appearance, treatment-resistant deformities and referred patients should be warning signs for complex clubfoot.

Comparison of efficacy between combined periarticular and incisional injections versus periarticular injection alone of bupivacaine for pain control after total knee arthroplasty: A prospective randomized controlled trial.

OBJECTIVE: The aim of this study was to compare the efficacy of combined periarticular and incisional injections versus periarticular injection alone of bupivacaine in reducing post-operative pain after total knee arthroplasty (TKA). METHODS: In this prospective, randomized, double-blind comparative study, 90 patients with primary osteoarthritis who underwent TKA were enrolled. The patients were then randomly divided into 3 groups (30 in each): group 1, without injection; group 2, with periarticular injection of 20 mL 0.5% bupivacaine hydrogen chloride (HCl) (100 mg) after implantation; and group 3, periarticular injection of 20 mL 0.5% bupivacaine HCl (100 mg) after implantation and incisional injection of 10 mL 0.5% bupivacaine HCl (50 mg) before wound closure. Post-operative pain levels were measured using a 100-mm visual analogue scale (VAS) (0 mm: no pain and 100 mm: worst pain) at 30 min and 1, 2, 4, and 6 h, post-operatively. RESULTS: The mean VAS score in group 3 (the combined group-periarticular and incisional injections) within the first 4 h was lower than that in group 1 and group 2 (p<0.001). The mean VAS scores at the first 30 min were 65.21±9.46 in group 1, 51.86±5.96 in group 2, and 29.33±8.55 in group 3 (p<0.001). The mean VAS scores at the first 1 h were 64.43±9.32 in group 1, 47.26±4.77 in group 2, and 31.66±7.37 in group 3 (p<0.001). The mean scores at the 2 h were 61.46±8.62 in group 1, 48.33±4.66 in group 2, and 30.83±6.76 in group 3 (p<0.001). The mean scores at the 4 h were 64.72±8.91 in group 1, 47.53±4.35 in group 2, and 34.36±6.64 in group 3 (p<0.001). The differences were not significant at 6 h between group 2 (44.91±4.12) and group 3 (41.83±6.71) (p>0.001). However, the values were significantly lower than those of the control group (63.56±9.73) (p<0.001). In addition, VAS scores at all follow-up times were significantly higher in the control group compared with the other groups (p<0.001). CONCLUSION: Evidence from this study revealed that the combined injection of bupivacaine is more effective than its periarticular injection alone and provides effective post-operative pain management after TKA. LEVEL OF EVIDENCE: Level I, Therapeutic study.

Resistive index and peak systolic velocity for congenital talipes equinovarus: A color Doppler ultrasonography study.

OBJECTIVES: This study aims to investigate whether resistive index (RI) and peak systolic velocity (PSV) are suitable parameters to determine if a clubfoot differs from feet of the normal population. PATIENTS AND METHODS: Fifty-four feet of 27 clubfoot patients (22 males, 5 females; mean age 30.4±16.3 months; range, 5 to 72 months) were included in this retrospective study conducted between December 2017 and January 2019. Twenty-seven feet were conservatively treated, 19 had surgical treatment, and eight feet were healthy in patients with unilateral clubfoot. In addition, 22 feet of 11 normal controls (6 males, 5 females; mean age 33.4±15.3 months; range, 15 to 60 months) were studied. Color Doppler ultrasonography examinations were performed to evaluate the three major arteries of the leg and foot: dorsalis pedis (dp), tibialis posterior (tp), and popliteal (pop). Color filling, flow direction, spectral analysis, velocity, and RI were examined. RESULTS: With the exception of the dp artery RI, the PSV and RI values for all arteries differed significantly from those of the control group. There were no significant differences among the conservative, surgical, and healthy groups, while there were significant differences between each of the treated groups and the control group. Tibialis posterior artery PSV and pop artery RI were the best parameters to identify clubfoot and the cut-off points were 54 cm/second and 0.77, respectively. CONCLUSION: Peak systolic velocity and RI may be accepted as important parameters for identification of clubfoot deformity. Tibialis posteriorartery PSV and pop artery RI are the best- detailed parameters for this examination.