Effect of muscle atrophy and fatty infiltration on mid-term clinical, and functional outcomes after Achilles tendon repair.

OBJECTIVES: Muscle atrophy is one of the most common problems after Achilles tendon repair. The aim of this study was to evaluate the effect of gastrosoleus muscle atrophy and fatty infiltration on clinical, and functional outcomes after Achilles tendon repair. MATERIAL AND METHODS: A total of 46 patients (mean age = 39.3 ± 7.4 years) who underwent open Achilles tendon repair were included in the study. During the clinical evaluation of muscle atrophy, ipsilateral and contralateral calf circumference (CC), maximum heel rise (HR), and ankle range of motion measurements were recorded. Functional outcomes were assessed via The Achilles tendon Total Rupture Score (ATRS), the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and the Leppilahti score. Muscle volume (MV), cross-sectional area (CSA), and percent of fatty infiltration (FI) were measured via magnetic image resonance. RESULTS: The functional outcome scores were excellent: ATRS = 98.1 ± 2.2; AOFAS = 97.3 ± 4.1; Leppilahti score = 95.8 ± 5.1. There were significant differences detected between injured and non-injured legs regarding CC, HR, MV, CSA, and FI. Additionally, there were significant negative correlations between CSA and MV loss with all functional outcome scores. FI was correlated with only the AOFAS ankle-hindfoot score. CONCLUSIONS: Significant muscle atrophy was measured after a mean follow-up period of 7.4 (range 2.0-12.6) years post-surgery and negatively correlated with clinical outcomes. CC is an easy and cost-effective measurement method to predict MV during the follow-up of Achilles tendon repairs.

Intramedullary nailing versus percutaneous locked plating of distal extra-articular tibial fractures: a retrospective study.

The aim of this study is to compare distal tibial fractures (4-10 cm proximal to the plafond) treated by intramedullary nailing with those treated by percutaneous locked plating and to assess the clinical and radiographic results, complication rates, and the need for secondary procedures. Thirty-six patients received percutaneous locked plate treatment and 25 patients received intramedullary nail treatment. The results obtained from these two treatment methods were assessed by comparing infection rates, starting time for wight-bearing, local implant irritation, union and malunion rates and along with secondary procedures. In the percutaneous locked plate group, two deep infections, four superficial infections, two nonunions, one malunion and 10 local implant irritations were observed. In the intramedullary nail group, one nonunion, four malunions and two local implant irritations were observed. The incidence of deep and superficial infections, local implant irritations and secondary procedures in the percutaneous locked plate group was greater than those in the intramedullary nail group. The time to full weight bearing was shorter in the intramedullary nail group. There was no significant statistical difference in malunion and nonunion rates between the two groups. The need for secondary procedures was more common in group receiving the percutaneous locked plate treatment and the time to full weight bearing was shorter in the intramedullary nail group.

Comparison of reduction methods in intramedullary nailing of subtrochanteric femoral fractures.

OBJECTIVE: The aim of this study was to compare the outcomes of three reduction methods used during intramedullary nailing of the subtrochanteric femur fractures. METHODS: This study included 45 patients with subtrochanteric femur fractures who were treated with intramedullary nailing. Twenty-two patients underwent clamp-assisted reduction, 11 reduction with cable cerclage, and 12 with blocking screws. Reduction techniques were compared with respect to the early postoperative alignment, one year postoperative alignment, time to full weight-bearing, time to union, Harris hip score at one year, operation and fluoroscopy times, blood transfusion amount, complications, and additional interventions. RESULTS: The clamp-assisted reduction group had a statistically high mean time to full weight-bearing (p=0.038) and a low mean Harris hip score at one year (p=0.002). The blocking screw group's operation times and fluoroscopy times were statistically long. There was no statistically significant difference between the clamp-assisted reduction and cable cerclage groups in terms of operation times and fluoroscopy times. On the other hand, there were statistically significant differences between the clamp-assisted reduction and blocking screw groups (p=0.0001 and p=0.0001, respectively) and between the cable cerclage and blocking screw groups (p=0.037 p=0.0001, respectively) in terms of operation times and fluoroscopy times. There was no statistically significant difference between the clamp-assisted reduction, cable cerclage and the blocking screw groups in terms of early postoperative alignment, one year postoperative alignment, time to union, complications or additional interventions. CONCLUSION: Clamp-assisted reduction leads to a longer time to weight-bearing and a poorer functional status at one year. Operation time and fluoroscopy time were longest in the blocking screw group.

Avascular necrosis of the femoral head after hip arthroscopy.

We report a case of a 61-year-old woman who underwent hip arthroscopy for a labral tear. The acetabular labrum was resected arthroscopically. Three months later, magnetic resonance imaging showed avascular necrosis of the femoral head. Theoretically, avascular necrosis following hip arthroscopy may result from traction on vessels supplying the femoral head, direct injury to such vessels during portal entrance, raised intra-articular pressure, prolonged operating time and damage to vessels during bony resection or osteochondroplasty for femoroacetabular impingement. We presume that avascular necrosis in our case was a result of a traction injury and increased intra-articular pressure.

Cementless bilateral total hip arthroplasty in a patient with a history of pelvic irradiation for sarcoma botryoides.

OBJECTIVE: To report a case of bilateral secondary coxarthrosis in a patient with a history of pelvic irradiation for sarcoma botryoides. CLINICAL PRESENTATION AND INTERVENTION: The patient had surgery and radiation therapy for sarcoma botryoides when she was 18 months old. Left and right cementless total hip arthroplasties were performed at the age of 36 and 40 years, respectively. Harris hip scores improved from 28.4 to 93 on the left hip after 84 months of follow-up and from 29.5 to 91.3 on the right hip after 38 months of follow-up. CONCLUSION: Cementless total hip arthroplasty may be considered for irradiated hips, if radiation damage in bone has been stable for a long period of time.

Evaluating the effectiveness of a deep-vein thrombosis prophylaxis protocol in orthopaedics and traumatology.

RATIONALE, AIMS AND OBJECTIVES: To evaluate the effectiveness of the deep-vein thrombosis (DVT) prophylaxis protocol for adult patients in a general orthopaedics and traumatology clinic. METHOD: We followed the DVT prophylaxis protocol in 1326 (776 female, 550 male) of 2114 adult patients admitted to the Department of Orthopaedics and Traumatology in Goztepe Research and Training Hospital. They were followed for symptomatic DVT and possible complications of low-molecular-weight heparin (LMWH) therapy. A Doppler ultrasonography (US) was performed when DVT was suspected. The medical information treatment protocols of DVT patients were recorded. RESULTS: Doppler US was performed in 58 patients with suspected DVT. Six of these patients were diagnosed with DVT. The side effects of LMWH were upper gastrointestinal bleeding (0.5%), widespread ecchymosis of the extremities (1.9%) and heparin-induced thrombocytopenia (0.16%). CONCLUSION: Symptomatic DVT occurrences were similar to those in medical literature; however, there were fewer side effects of LMWH than reported in literature.

A clay-shoveler's fracture with renal transplantation and osteoporosis: a case report.

INTRODUCTION: Clay-shoveler's fracture is a rare cervicodorsal spinous process fracture and there is little information regarding the prognosis of patients with this condition in conjunction with osteoporosis and corticosteroid use. CASE PRESENTATION: A 39-year-old man was admitted to our institution with a 6-month history of cervicodorsal pain prior to admission. The patient had previously undergone renal transplantation and was on corticosteroids, and had developed osteoporosis. We treated him with a cervical collar, non-steroidal anti-inflammatory agents and alendronate. The patient was advised against performing weight-bearing activities for 6 months. CONCLUSION: Clay-shoveler's fracture with osteoporosis and corticosteroid use presented by fracture of the cervicodorsal aspect of the spinous processes may be successfully treated with a collar, alendronate and long-term rest.

Patients with isolated musculoskeletal trauma have lower mental status scores.

UNLABELLED: The subjective concerns and needs of patients who have experienced trauma are important to recovery. However, the mental status of patients with isolated musculoskeletal trauma is not known. Is the mental status of such patients different and does the severity, site, and type of trauma affect this difference? We evaluated the mental status of 195 patients hospitalized for isolated musculoskeletal trauma and determined the characteristics of the factors that affect mental status; 197 patients hospitalized for elective surgery and not exposed to acute trauma constituted the control group. We administered the Mini-Mental State Examination to study and control groups within the first 24 hours of hospitalization. Age, gender, and educational status in the study and control groups were recorded. In addition, the severity, site, and type of trauma in the study group were recorded. Mini-Mental State Examination scores of the trauma group were lower than those of the control group. Mini-Mental State Examination scores decreased with increasing trauma severity. The mental status of the patients sustaining isolated musculoskeletal trauma was affected by the severity, site, and type of trauma. LEVEL OF EVIDENCE: Level I, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Early tunnel enlargement after arthroscopic ACL reconstructions.

The aim of this study was to evaluate the tunnel enlargement phenomenon after ACL reconstructions performed with hamstrings tendons fixed using the cross pin technique. Sixty-two knees in 62 patients were followed for two years to evaluate the possible clinical implications of the femoral and tibial tunnel enlargements noted after ACL reconstruction. The reconstructions were done with hamstring tendons using the cross-pin technique. Evaluation was based on calculated clinical scores (IKDC and Lysholm knee scores) and quantified by KT-1000 measurements. Sagittal and coronal plane computed tomography and conventional radiography were performed 3 days after operation and were repeated after 3 and 6 weeks, 6, 12 and 24 months, to assess early tunnel enlargement. Although it seems that tunnel enlargement after ACL reconstruction has no impact on the clinical results, long-term implications and potential need for revision surgery must be assessed. In this study, tunnel enlargement was noted fairly early after operation and was thought to be related with drilling of the tunnels. A possible solution to this problem may be drilling the tunnels to a diameter 1 mm smaller than the measured graft diameter, then to enlarge the tunnels to the graft diameter with the appropriate tunnel dilator.

[Total hip arthroplasty in the treatment of developmental dysplasia of the hip]. / Gelisimsel kalça displazisinde total kalça protezi.

Total hip arthroplasty (THA) is the preferred treatment for patients with severe arthritis of the hip secondary to developmental hip dislocation or dysplasia. However, THA may be difficult due to bone and soft tissue problems that arise from hip dislocation or dysplasia. Another problem is that patients are usually young, which may affect the long-term survival of the prosthesis. Either cemented or uncemented components can be used depending on bone structure and bone stock. Uncemented components are more preferable because of the young age of the patients. From a biomechanical standpoint, the placement of the acetabular component in its true anatomical location is the main goal for survival and better functional results of THA. To ascertain the stability of the acetabular component, superior grafting, controlled medial wall perforation (medialization), or giving the position of a high hip center may be used. On the femoral side, various femoral components may be used with or without a shortening osteotomy. In this article, reconstruction options for developmental hip dysplasia are discussed depending on acetabular and femoral features of the deformity.

Extravascular compression of the femoral vein due to wear debris-induced iliopsoas bursitis: a rare cause of leg swelling after total hip arthroplasty.

We present a patient with unilateral, spontaneous, late leg swelling that developed 4 years after total hip arthroplasty. The etiology was the compression of the internal iliac vein by a voluminous iliopsoas bursitis caused by polyethylene debris. The expansive lesion was detected by ultrasound, arthrography, and magnetic resonance imaging. An ultrasound-guided aspiration provided transient relief of the patient's symptoms. The patient later required surgical excision through an abdominal approach. A second recurrence was detected and treated with revision surgery. We present the diagnosis and the treatment of this rare cause of late, unilateral leg swelling after total hip arthroplasty together with a review of the literature.

[Treatment of shoulder impingement syndrome after coronary artery bypass surgery]. / Koroner arter baypas ameliyati sonrasi olusan omuz sikisma sendromunun tedavisi.

OBJECTIVES: A treatment protocol was developed for shoulder impingement syndrome in patients undergoing major thoracic surgery and the results were compared with those of a control group. METHODS: Treatment with steroids and local anesthetics was administered to 17 patients (15 males, 2 females; mean age 62 years; range 52 to 68 years) who developed impingement syndrome after coronary artery bypass surgery, and to 17 control patients (6 males, 11 females; mean age 56 years; range 43 to 67 years) who did not have thoracic surgery but had impingement syndrome. Injections were made subacromially, around the biceps tendon, intraarticulary, and in the posterior pericapsular area. After the injections, conservative therapy was given, which also included at least six weeks of the Jackins physical therapy program. The patients were assessed before and 3, 6, 9 and 12 months after the treatment with the use of the UCLA (University of California at Los Angeles) scoring system. RESULTS: Before the treatment, the UCLA scores were poor in all the patients in both groups. The results of the treatment in the thoracic surgery group at the end of a year were excellent in 12 patients (70.6%) and good in five patients (29.4%). In the control group, five patients (29.4%) were rated as excellent, eight patients as good (47.1%), and four patients as poor (23.5%). CONCLUSION: Compared to controls, patients that develop shoulder impingement syndrome following major thoracic surgery benefit from steroid-local anesthetic injections and short-term conservative therapy with a far better response characterized by early relief of pain and rapid improvement in the shoulder range of motion.

Avulsion fracture of the posterior cruciate ligament at the tibial insertion in a child: a case report.

The posterior cruciate ligament (PCL) avulsion fracture from its tibial insertion is a very rare condition in children. An isolated avulsion fracture of PCL in a child and its repair by open reduction and internal fixation with a screw is reported.

[Risk factors for osteoporosis in women having hip fractures after 60 years of age]. / Kalça kirikli 60 yas üstü kadinlarda osteoporoz risk faktörleri.

OBJECTIVES: Management of hip fractures in elderly women should not be confined to surgical treatment and rehabilitation, but also encompasses interventions and measures to protect them from hip fractures. We administered a questionnaire to female patients with hip fractures to determine their social profiles and risk factors. METHODS: A total of 107 female patients (mean age 74 years; range 63 to 100 years) who experienced hip fractures after the age of 60 years were administered a questionnaire to determine their physical and social characteristics, medical conditions , and nutritional status. In addition, the types of fractures and the Singh index were determined on hip radiographs. Femoral neck (n=51, 47.7%) and intertrochanteric (n=56, 52.3%) fractures were classified according to the Garden and modified Evans classifications, respectively. RESULTS: The mean body mass index was 23 kg/m2. The Singh index was grade 3 in 70.1%, grade 2 in 26.2%, grade 4 in 2.8%, and grade 1 in 0.9%. Forty-four patients (41.1%) were illiterate, and 31 patients (29%) were only literate or could finish primary school. A history of smoking was found in 29.9% for a mean duration of 30.7 years. The majority of patients (67.3%) had limited activity and 63.6% had no outdoor work at all. None of them had a regular sport activity. Only two patients (1.9%) received inadequate and short-term postmenopausal therapy. The mean daily milk consumption was less than a glass (125-150 ml). Calcium supplements were used in only 5.6%. A history of previous fractures (hip, vertebra, distal radius) was detected in 9.3%. The most common coexistent diseases were hypertension (50%) and diabetes (29%). None of the patients had bone mineral density measurements. CONCLUSION: Our study showed that, despite the high incidence of risk factors for osteoporosis, few patients received medical care for the diagnosis and treatment of osteoporosis, and that preventive health care measures were not available for this patient group.

Polygonal triple (Kotz) osteotomy in the treatment of acetabular dysplasia: 17 patients (19 hips) with 4-9 years of follow-up.

We reviewed 19 hips in 17 patients between 17 and 33 years of age, who underwent a Kotz polygonal triple osteotomy. Their average follow-up was 7 (4.5-9) years. Although 13 patients had less pain after surgery, 3 continued to limp. The average corrections were 36 degrees for the center-edge angle, 31 degrees for the vertical center-edge angle and 19 degrees for Sharp's angle. 3 patients developed transient palsy of the sciatic nerve, and 3 asymptomatic nonunion of the ischium or pubic bone. The degree of arthrosis decreased in 10 hips.

Kotz and Ganz osteotomies in the treatment of adult acetabular dysplasia.

In hips with acetabular dysplasia, we performed Kotz osteotomy (group 1) in 22 hips (20 patients; mean age 24.3 years) and Ganz osteotomy (group 2) in 23 hips (22 patients; mean age 23.1 years). Group 1 was followed 83.3 (56-112) months and group 2 40.9 (24-66) months. In group 1, Harris hip score improved from average 74.9 to 86.9, mean center edge (CE) angle from -4.5 degrees to 30.3 degrees, and mean vertical center edge (VCE) angle from 5.3 degrees to 36.2 degrees. In group 2, Harris hip score improved from average 76.6 to 91.1, mean CE angle from -5.9 degrees to 32.0 degrees, and mean VCE angle from 5.0 degrees to 41.3 degrees. Using Pauwels criteria, regression was observed in 12 hips in group 1 and one progressed. In group 2, 15 hips showed regression and three progressed. In patients treated with Ganz osteotomy, the complication rate was higher and the complications more serious than in patients treated with Kotz osteotomy. Most complications were, however, seen among the first ten patients treated with Ganz osteotomy. Although we detected no significant difference between the two groups in terms of clinical and radiological findings, we believe the outcome to be slightly better after a properly performed Ganz osteotomy.

Effect of diclofenac sodium on union of tibial fractures in rats.

Nonsteroidal anti-inflammatory drugs are often used for 7 to 10 days after fracture because of their effects on bone metabolism. This study evaluated the effect of diclofenac sodium, administered at clinical dosage and duration, on bone union. Fifty-four male Wistar rats were randomly and equally divided into three groups: control, diclofenac 1 mg, and diclofenac 2 mg. Closed diaphyseal fractures were induced in the right tibias of all rats; the two diclofenac groups received intramuscular injections in the contralateral hips for 10 days. All animals were immobilized in circular casts on the upper thighs. Six rats in each group were sacrificed at weeks 2, 4, and 6, and bony union was evaluated clinically, radiologically, and histologically. At the end of 2 weeks, clinical examinations showed subjective differences between the two treated groups and control animals, with more stable callus formation in controls. Radiologic evaluation of the callus showed numeric, but not significant, differences between control and treated animals. At 4 and 6 weeks, clinical and radiologic findings were comparable among groups. Histologically, no significant differences in callus formation were evident at any evaluation.

Femoral shortening and cementless arthroplasty in high congenital dislocation of the hip.

We performed cementless total hip arthroplasty with femoral shortening in 28 hips of 23 patients with high-riding congenital dislocation of the hip. All the acetabular cups were placed in their original anatomic location. If needed, the acetabulum was reconstructed using the femoral head. The proximal diaphyseal step-cut shortening osteotomy was performed and stabilized by cerclage or cable grips. The follow-up results at average 48 months postoperatively were scored clinically by the Merle D'Aubigné and Harris hip scores and were good and excellent in 89.2%. One acetabular cup showed progressive radiolucent lines suggesting aseptic loosening. Two superficial wound infections, 1 femoral nerve palsy, 1 sciatic nerve palsy, 2 nonunions, and 1 acetabular fracture were observed during the follow-up.

Failure strength of repair devices versus meniscus suturing techniques.

The purpose of this study was to compare the load to failure of different common suturing techniques with repair devices. Seventy-one calf medial menisci were cut to simulate peripheral longitudinal tears and repaired with one of 13 repair techniques. The two parts of the meniscus were pulled using the Instron tensometer until failure occurred. The techniques and repair devices tested were vertical (0 PDS, 2-0 PDS, 2-0 Ethibond), horizontal (0 PDS, 2-0 PDS, 2-0 Ethibond) suturing, T-fix, Mitek, Clearfix screw, Clearfix dart, Biostinger, S-D-sorb, and Artrex dart. The strongest repair method in our study was the vertical sutures with 0 PDS. In this study the mean failure strength of all meniscal repair devices was lower than that of the vertical and horizontal suturing techniques. All meniscus repair devices except T-fix and in some the Arthrex dart (40% broken up) pulled out of the menisci. Devices which had only horizontally placed barbs had lower mean failure strength. Failure strength of T-fix was similar to horizontal sutures with 2-0 Ethibond and 2-0 PDS. In conclusion, because all meniscal repair devices had inferior results, when such devices are used, postoperative rehabilitation should not be hastened, and their inferior primary stability should be kept in mind.

[Total hip arthroplasty and problems encountered in patients with high-riding developmental dysplasia of the hip]. / Yüksekte dogustan kalça çikiginda total kalça protezi ve karsilasilan sorunlar.

OBJECTIVES: We evaluated total hip arthroplasty in patients with high-riding developmental dysplasia of the hip with regard to surgical method and modifications, problems encountered during surgery, and follow-up results. METHODS: A total of 42 hips (22 Crowe type III, 20 type IV) of 31 patients (29 women, 2 men; mean age 45.7 years; range 26-70 years) who underwent total hip arthroplasty were clinically and radiologically evaluated. In all cases, cementless acetabular components were placed in the true acetabulum. Fifteen acetabula required structural autografts. Cementless stems were used on the femoral side. Proximal metaphyseal step-cut osteotomy was performed in patients with high-riding hips of more than 4 cm. The mean follow-up period was 54.7 months (range 11 to 127 months). RESULTS: The mean Harris hip score increased from 37.6 preoperatively to 91.02 at the end of follow-up. No acetabular autograft resorption or non-union were observed. Non-union and delayed union in the femoral osteotomy site were encountered in two patients, respectively. Two components (1 acetabular, 1 femoral) were revised during the follow-up period. Two sciatic and two femoral temporary nerve palsies occurred. One patient developed superficial infection and was treated by debridement and antibiotics. Brooker type I heterotopic ossification was observed in seven patients. CONCLUSION: Total hip arthroplasty proved successful in high-riding developmental dysplasia of the hip.