The utility of standing knee radiographs for detection of lipohemarthrosis: comparison with supine horizontal beam radiographs.

OBJECTIVES: Lipohemarthrosis is a key finding in acute trauma patients and indicates an intra-articular fracture. The horizontal beam lateral radiography with supine position is known to be the best technique to demonstrate knee lipohemarthrosis. Our main purpose was to compare the sensitivity of supine and standing lateral knee radiographs to detect lipohemarthrosis. METHODS: In our retrospective study, consecutive patients with lipohemarthrosis on computed tomography of the knee between October 2019 and September 2021 were included. Fractured bone, the presence of lipohemarthrosis, and image quality in both standing and supine anteroposterior and lateral knee radiographs were evaluated. Interobserver reliability of the three observers was calculated. Fisher exact chi-square and z-proportion tests were used to compare lateral and anteroposterior knee radiographs. Krippendorff's Alpha and Kappa coefficients were used for inter-observer agreement. RESULTS: A total of 61 patients (38 men [62.3%], 23 women [37.7%]; mean age, 43 years ± 17 [standard deviation]) were included. The most common type of fracture was isolated tibial fractures (n = 32; 52.5%). The sensitivity of showing lipohemarthrosis of standing lateral knee radiographs (95.5%) was higher than supine lateral radiographs (38.5%) (p < 0.001). While non-optimal image quality did not affect lipohemarthrosis detection on lateral radiographs (p > 0.99), it caused a significant decrease in the diagnosis of lipohemarthrosis on anteroposterior radiographs (p = 0.036). We found a good-excellent interobserver agreement in lipohemarthrosis detection. CONCLUSIONS: Standing lateral radiographs have higher sensitivity than supine lateral radiographs in detecting lipohemarthrosis and are beneficial for detecting lipohemarthrosis which indicates the presence of occult-evident intraarticular fracture in patients with knee trauma. CLINICAL RELEVANCE STATEMENT: Standing lateral knee radiographs offer a useful method for reducing the misdiagnosis of the occult intra-articular fractures by showing the fat-fluid leveling more clearly. Its advantages may be more prominent when the advanced imaging modalities are limited. KEY POINTS: • Fat-fluid level (lipohemarthrosis) is an important radiographic sign to assess patients with acute trauma. It almost always indicates an intra-articular fracture. • Our retrospective study results support that lipohemarthrosis sign could be observed more frequently in standing lateral knee radiographs than in supine lateral radiographs. • Knee trauma patients, when available, should be evaluated with standing lateral radiographs for the diagnosis of lipohemarthrosis.

Prognostic nutritional index (PNI) is an independent risk factor for the postoperative mortality in geriatric patients undergoing hip arthroplasty for femoral neck fracture? A prospective controlled study.

INTRODUCTION: Hip fracture is very common in advanced ages, and it is very likely that this condition is accompanied by nutritional deficiencies. The aim of this study was to investigate the effect of prognostic nutritional index (PNI) on postoperative mortality in geriatric patients who underwent hip arthroplasty for femoral neck fracture. MATERIALS AND METHODS: Geriatric patients (aged ≥ 70 years) who underwent hip arthroplasty for femoral neck fracture were prospectively recruited. The patients' demographic data, time until surgery, total hospital stay, perioperative blood transfusion, duration of surgery and anesthesia, serum albumin level, total lymphocyte count, PNI value, and first-year mortality were examined. They were divided into two groups as patients who died and those who did not die within the 1st year, and between-group comparisons for continuous and categorical variables were made using independent t test and Chi-square test, respectively. Receiver operating characteristic (ROC) curve was constructed, and a cutoff value for PNI was determined based on sensitivity and specificity values. RESULTS: The total number of participants was 124. The mean age was 80.40 ± 7.19 years: 77 (62.1%) were female and 47 (37.9%) were male. PNI was statistically significant for 1-year mortality in multivariate Cox regression analysis (p < 0.05). According to ROC curve analysis, the area under the curve for PNI level was found to be 0.764 (95% CI 0.670-0.857), and this value was statistically significant (p < 0.001). The sensitivity and specificity for the 38.4 cutoff value were 83.9% and 39.8%, respectively. The mean age, time after surgery, total hospital stay, and preoperative blood transfusion need were found to be statistically higher in the patients with low PNI levels (≤ 38.4) than those in the other patients (> 38.4) (p < 0.05 for all). CONCLUSION: PNI seems to be an independent risk factor on mortality after hip fracture surgery in geriatric patients. PNI is a preventable and correctable risk factor that affects patient survival.

Unusual Cause of Lateral Elbow Pain: A Case Report of Anconeus Muscle Contusion.

The anconeus muscle is a small and minor functioning muscle located at the posterolateral elbow region. It helps forearm extension and tightening of the joint capsule. Despite its limited functions, pathologies of the anconeus muscle can mimic other abnormalities of the elbow joint. Here, we report a rare case of a traumatic anconeus muscle contusion in a 15-year-old boy due to falling during dance. MRI showed contusion in the anconeus muscle, as well as strain in the ulnar collateral ligament and edema in the coronoid process of the ulna. To our knowledge, this is the first described case of traumatic anconeus muscle contusion in the literature. The presence of long-lasting lateral elbow pain in trauma cases without fracture should alert clinicians to consider anconeus muscle abnormalities. MRI is the best modality for diagnosis in these cases.

Computed tomography evaluation of the iliac crest apophysis: age estimation in living individuals.

Determination of the ossification properties of the iliac apophysis is important not only in the clinical evaluation of patients undergoing orthopedic surgery but also in age estimation studies for forensic purposes. The literature includes both anthropological and radiological (conventional radiography, ultrasonography, and magnetic resonance imaging modalities) investigations of the different staging systems used for these purposes. In this study, we assessed the utility of computed tomography (CT) of the iliac crest apophysis in estimating forensic age. CT scans of the iliac crest apophysis of 380 patients (187 females, 193 males, and 10-29 years of age) were evaluated according to the four-stage system. Further subclassification did not give data properly due to the reference length measurement of the iliac wing with CT. Thus, in our series, stage 2 was first seen in 12 years of age and stage 3 in those 14 years of age in both sexes and on both sides of the pelvis. Stage 4 was first seen in 17 years of both sexes but only on the right side; on the left side, it appeared in females 18 years of age and in males 17 years of age. Present data was found consistent with previous pelvic radiographic findings. First seen ages for stage 2 and 3 are 12 and 14 years respectively which presented valuable information for legally important age thresholds. However, disadvantages of CT, including high-dose radiation exposure to gonads, the difficulty of evaluating the iliac crest, and the age boundary of 17 years, could make this method infeasible, as compared with hand wrist and pelvic radiographic methods. CT of the iliac crest has probably a greater utility where preexisting CT scans of the pelvic region are available, and it may be considered as a supportive method for age-estimation purposes.

Medial percutaneous hemi-epiphysiodesis improves the valgus tilt of the femoral head in developmental dysplasia of the hip (DDH) type-II avascular necrosis.

BACKGROUND AND PURPOSE: Avascular necrosis (AVN) is a major cause of disability after treatment of developmental dysplasia of the hip (DDH), leading to femoral head deformity, acetabular dysplasia, and osteoarthritis in adult life. Type-II AVN is characterized by retarded growth in the lateral aspect of the physis or by premature lateral fusion, which produces a valgus deformity of the head on the neck of the femur. We investigated the effect of medial percutaneous hemi-epiphysiodesis as a novel technique in the treatment of late-diagnosed type-II AVN. PATIENTS AND METHODS: 9 patients (11 hips) with a diagnosis of type-II AVN who underwent medial percutaneous hemi-epiphysiodesis after the surgical treatment for DDH were included in the study. 10 patients (12 hips) with the same diagnosis but who did not undergo hemi-epiphysodesis were chosen as a control group. Preoperative and postoperative articulotrochanteric distances, head-shaft angles, CE (center-edge) angles, and physeal inclination angles were measured. The treatment group underwent medial hemi-epiphysodesis at a mean age of 8 years. The mean ages of the treatment group and the control group at final follow-up were 14 and 12 years respectively. The mean duration of follow-up was 5.7 years in the treatment group and 8.3 years in the control group. RESULTS: Preoperative articulotrochanteric distance, head-shaft angle, and functional outcome at the final follow-up assessment were similar in the 2 groups. However, preoperative and postoperative CE angles and physeal inclination angles differed significantly in the treatment group (p < 0.05). The final epiphyseal valgus angles were better in the treatment group than in the control group (p = 0.05). The treatment group improved after the operation. INTERPRETATION: Medial percutaneous epiphysiodesis performed through a mini-incision under fluoroscopic control is a worthwhile modality in terms of changing the valgus tilt of the femoral head.

How are outcomes affected by performing a one-stage combined procedure simultaneously in bilateral developmental hip dysplasia?

PURPOSE: The aim of this study was to compare the outcomes of one-stage combined surgical treatment in children of unilateral and bilateral developmental hip dysplasia diagnosed after walking age. METHODS: We reviewed 24 patients who underwent one-stage combined surgery for DDH diagnosed after walking age. Group I consisted of 12 patients with bilateral disease who underwent bilateral operation at one operative setting. Group II consisted of 12 patients with unilateral disease. Pre-operatively the hips were classified according to Tönnis classification. Acetabular dysplasia was evaluated by measuring acetabular index (AI) angles pre-operatively. The acetabular improvements with time regarding AI was noted immediately postoperatively, every six months, and at the final follow-up examination. RESULTS: Mean follow up of the bilateral group I and group II were 54.8 months (range 20-84 months) and 52.6 months (24-80), respectively. There were no statistically significant differences between immediate postoperative and final follow up acetabular index improvement rates in both groups. Also there was no significant difference when both hips were compared in group I. The clinical final outcome of both groups and within group I was similar. CONCLUSIONS: Simultaneous combined surgery is a challenging but worthwhile procedure for late diagnosed patients with bilateral DDH. The short-mid term outcomes of the procedure are encouraging.

Scapholunate dissociation associated with distal radius fractures.

OBJECTIVE: The exact prevalence of scapholunate dissociation (SLD) associated with distal radius fracture (DRF) and the effect of persistent SLD on the function of the wrist are not known. So, we examined the association between SLD and DRF and the effects of treatment on clinical outcomes. METHODS: Eight hundred and twenty-nine patients with 839 DRF were included in the study. The radiographs of the patients were examined with special reference to SLD both in pre- and post-reduction period. Persistent SLD cases were evaluated by the scoring system of Green and O'Brien at least 2 years after the fracture. RESULTS: Of the 839 fractures, 215 had SLD after the injury. When post-reduction radiographs were examined, SLD persisted in 98, but in 14 SLD was detected in the post-reduction period while not apparent in initial radiographs. So, a total of 112 patients (13.4%) had persistent SLD. Nineteen patients were lost to follow-up and remaining 93 wrists examined clinically. Seventy-nine had pain on the scapholunate joint and 14 had not. When these patients were evaluated by Green and O'Brien system, symptomatic patients had fair or poor results but asymptomatic had good. The association between DRF and SLD is 13.4%. CONCLUSIONS: Severity of the distal radius fractures is not associated with SLD. Intra-articular fractures were associated with significant increase in the prevalence of SLD. In some cases, SLD may appear after reduction in distal radius. Most cases with SLD are symptomatic, and this may be the reason of poor cases following distal radius fracture.

Split Transfer of the Tibialis Anterior Tendon Combined With Calcaneocuboid Fusion vs Split Transfer of the Tibialis Anterior Tendon Alone to Treat Equinovarus Foot Deformity in Children With Cerebral Palsy.

BACKGROUND: The study aimed to compare the outcomes of combined calcaneocuboid arthrodesis and split anterior tibialis tendon transfer (SPLATT) procedure to isolated SPLATT surgery for the treatment of the spastic equinovarus deformity in children with cerebral palsy (CCP). METHODS: Forty-one ambulatory CCP with 56 equinovarus feet, with positive flexor withdrawal reflex test results, were studied. The average age was 9.1 ± 3.2 years (range 3-22). Patients were assigned into 2 groups based on the surgical procedures. Patients in group 1 underwent isolated SPLATT surgery, whereas patients in group 2 underwent the SPLATT procedure combined with calcaneocuboid arthrodesis. All feet were followed for at least 12 months after surgery. Patients were evaluated preoperatively and at the most recent follow-up visit. The hindfoot positions were assessed using Chang's criteria, the functional outcomes were assessed using Kling's criteria, and the ambulatory levels were assessed using the Gross Motor Function Classification System (GMFCS). RESULTS: Patients were followed for an average of 30.4 ± 14 (range 14-84) months. We found no difference between the groups in Chang's scoring (P = .550), better clinical outcomes (P = .034) according to the Kling criteria in SPLATT with calcaneocuboid fusion group, and postoperative GMFCS levels better in the SPLATT with calcaneocuboid fusion group (P = .025). CONCLUSION: In this retrospective comparative study to treat children with spastic equinovarus feet, patients who had the SPLATT procedure combined with calcaneocuboid arthrodesis generally resulted in better functional outcomes compared to isolated SPLATT surgery in spastic equinovarus foot. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Is immediate internal fixation safe in induced membrane technique?

OBJECTIVES: This study aimed to evaluate the treatment outcomes of patients treated with induced membrane technique (IMT) for the reconstruction of bone defects and to identify factors associated with the success and failure of the modified technique. PATIENTS AND METHODS: Between January 2016 and April 2021, a total of 23 adult patients (20 males, 3 females; median age: 39.9 years; range, 20 to 69 years) who underwent bone reconstruction using the IMT for established pseudoarthrosis and acute bone loss were retrospectively analyzed. Fracture type, the size and location of bone defect, the nature of the index injury, the type of fixation, the interval between stages of the operation, and any diagnosis of infection or other complications of the patients were assessed. RESULTS: The median bone union was achieved in 6.6 (range, 4 to 11) months. The median index of reconstruction was 19 (range, 10 to 30%). The main complications were recurrent infection in two cases and nonunion in one case. Massive graft resorption occurred in two cases. CONCLUSION: Immediate internal fixation is a reliable and effective method in the treatment of complex bone defects. A large volume of autograft is required for the reconstruction of long defects, which presents as a limiting factor, particularly in patients undergoing previous surgical interventions.

Analysis of the factors affecting pain level during K-wire removal among pediatric elbow fractures.

Our aim was, to analyze the reasons for possible increased pain during the removal of the Kirschner wires from the elbows of children. From February 2021 to December 2021, 573 patients with elbow fractures were treated. In total, 150 patients were analyzed prospectively. No action was taken to reduce pain during the removal of Kirschner wires. The pain status of the patients was evaluated according to the Wong-Baker FACES Pain Rating scoring system (WBAS), the Numeric Rating Scale (NRS) for the pain system and the pulse and oxygen saturation measured by the pulse oximeter on the finger. Measurements were performed before, during, immediately after and 30 min after the procedure. There were 119 patients with a diagnosis of supracondylar humerus fracture and 31 patients with a diagnosis of lateral condyle fracture. The mean age of treated patients was 7.1 years (1-15 years). Of the patients, 93 were boys and 57 were girls. In the measurements made according to the sex difference, it was determined that there was a statistically significant increase in the WBAS scores measured both before the procedure ( P = 0.032) and during the removal ( P = 0.017), and also in the pulse measurements taken 30 min after the removal in girls ( P = 0.034). A statistically significant difference was found in both the WBAS score during removal ( P = 0.025) and the NRS scores 30 min later ( P = 0.048) in the procedures performed on the right elbow. We found a statistically significant increase in the pain parameters we evaluated in girls, right extremity fractures, the group over 8 years old and when both parents were with the child during the K-wire removal procedure. In light of these findings, physicians should consider the above-mentioned conditions before starting the procedure to ensure a less painful and positive experience.

Treatment of ankle varus deformity due to physeal bar formation: A case report.

Treatment of ankle deformities caused by the physeal bar after a fracture sequel is complicated. Each patient should be treated individually depending on of the severity of the deformity and bar location. We presented a case report of a successful treatment of an 11-year-old male patient with progressive varus deformity and bar formation due to trauma in the distal tibial physis. Tibia distal open wedge osteotomy, fibula closed wedge osteotomy, bar resection, and autogenic adipose tissue interposition were performed. The patient is at 4 year follow-up without any complication. We think that bar resection technique provides favorable results even in severe ankle deformity.

Does pin configuration matter in modified tension band wiring for transverse patellar fracture? A biomechanical study.

BACKGROUND: Modified tension band wiring has been widely used for the treatment of transverse patellar fractures. The optimal position of a Kirschner wire (K-wire) in modified tension band wiring, however, has not yet been determined. The purpose of the present study was to evaluate biomechanically the effect of K-wire position in a modified tension band wiring technique. METHODS: Forty-two polyurethane foam patellae with a midway transverse fracture were assigned to six different fixation groups regarding different pin configurations in tension band wiring. The depth or sagittal position of the K-wire was divided into anterior and posterior. The coronal position of the K-wire was divided into central, medial and lateral. A specially designed set up simulated a knee with 60° flexion. All specimens were tested under axial traction. Loads at 2 mm and 4 mm fracture displacement and at the failure of the construct were recorded. RESULTS: At 2 mm fracture displacement, anterolateral (AL) placement of K-wires revealed significantly less durability when compared with five other groups (P < 0.001). At 4 mm fracture displacement, the AL group also revealed inferior biomechanical strength when compared with other groups. Posteromedial (PM) K-wire placement group revealed more durability when compared with the posterolateral (PL) group (P < 0.05). At failure of the osteosynthesis, anteromedial (AM) and anterocentral (AC) groups revealed superior biomechanical strengths (P < 0.05). CONCLUSIONS: The coronal and sagittal position of K-wire affects the biomechanical characteristics of modified tension band wiring. Anterolateral placement of K-wires revealed inferior strength to all other constructs in modified anterior tension band wiring.

Management of tibial non-unions with Masquelet technique after failed previous treatment options for Grade III open fractures.

BACKGROUND: Non-union is a serious complication of open tibial fractures. This case series investigates the efficiency of the induced membrane technique in patients with tibial exposed non-union. METHODS: Eleven consecutive male patients with non-union after an open tibia fracture were enrolled into the study. The mean age of the patients was 40.7 (25-63). Induced membrane technique described by Masquelet was performed. Operative treatment with a temporary polymethylmethacrylate cement spacer to induce membrane formation followed by spacer removal and bone grafting at 7.35 (6-10) weeks were performed. Time to union, time to full weight-bearing, and any complications were evaluated. RESULTS: The average follow-up period of patients was 24.6 (13-40) months after the second stage. The mean length of bone defects after radical debridement was 51 mm (25-98). Fracture healing was observed in 9 patients (81%). The mean time needed to obtain bony union healing was 8.1 (8-12) weeks after second stage of surgery. Patients were allowed to full weight bearing as tolerated at 12 weeks. Two patients were failed to obtain bony union and infection control. One patient had below knee amputation due to persistant infection. Vascularized bone graft was performed for other patient due to the inability to obtain bone union. CONCLUSION: The induced membrane technique is a reliable and reproducible treatment modality for tibial non-unions after failed open fracture treatment. However, it is unpredictable to obtain bony union and control of infection in initial infected non-unions with a large bone defect.

Is It Necessary To Add Soft Tissue Injury to the Classification in Tibial Plateau Fracture Management?

Background A gold standard classification for the treatment of tibial plateau fractures with soft tissue injury has not been established yet.This study aimed to evaluate the usability of a novel modified classification that can provide preoperative information to the surgeon about soft tissue injuries in tibial plateau fractures. Methodology A total of 36 patients with tibial plateau fractures were included in the study. Patients' age, gender, and affected sides were recorded. Injuries to the medial meniscus, lateral meniscus, anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament, and lateral collateral ligament were examined with preoperative magnetic resonance imaging. Soft tissue injuries were arranged according to the novel modified classification based on the Schatzker classification. Results The mean age of the study participants was 45 (19-76) years; 72% of the patients were men and 28% were women. Moreover, 44% and 56% of the patients had broken the right and left tibial plateaus, respectively. At least one soft tissue injury was detected in 29 (81%) patients. In 14 (39%) patients, two or more soft tissue injuries were observed. All patients were arranged according to the novel modified classification regarding ligament and meniscus injuries. Conclusions With this novel modified classification system, we think that having better information about the preoperative condition of the soft tissue injuries can change the surgical strategy in patients with tibial plateau fractures.

Retroperitoneal migration of a septically loose femoral component.

Migration of total hip arthroplasty components is generally associated with a medial acetabular wall defect and may cause various intrapelvic complications. This is often a result of the destructive bone loss that takes place with infection. To our knowledge, this is the first report that presents complete intrapelvic migration of a femoral stem of total hip arthroplasty due to septic loosening with an intact medial acetabular wall.

The relationship between patellar tilt and quadriceps patellar tendon angle with anatomical variations and pathologies of the knee joint.

PURPOSE: To investigate the association between the knee joint anatomical variations and pathologies, and to describe the quadriceps patellar tendon angle (QPA). METHODS: MRIs of 406 cases with a lateral patellar tilt angle (LPT)>5° and a control group of 40 cases with an LPT<5° were retrospectively evaluated. QPA, LPT, trochlear sulcus angle (TSA), tibial tubercle-trochlear groove distance (TT-TG), Insall-Salvati index (ISI), patellar tendon length (PTL), patellar height (PH), lateral trochlear inclination (LTI), trochlear facet asymmetry ratio (TFA) and trochlear depth (TD) were measured. Presence of fat-pad oedema, patellar and trochlear chondromalacia, patellar and quadriceps tendinosis and effusion were evaluated. RESULTS: The medians of TSA, PTL, ISI and TT-TG were significantly higher; LTI, TFA and TD were significantly lower in the patient group. The prevalence of SL-Hoffa, non-SL-Hoffa, suprapatellar and prefemoral fat-pad oedema, effusion and chondromalacia were significantly higher in the patient group. LPT was found to be positively correlated with TSA and TT-TG, and negatively correlated with LTI and TD. Cases with trochlear dysplasia, patellar chondromalacia and quadriceps tendinosis had significantly higher LPT. There was a positive correlation between QPA and TSA and a negative correlation between QPA and LTI. Cases with trochlear dysplasia, non-SL-Hoffa oedema, prefemoral fat-pad oedema and quadriceps tendinosis had significantly higher QPA. We found 10°

Comparison of various surgical methods in the treatment of implant-related infection.

The treatment of implant-related infections is troublesome. This study was conducted to compare the effectiveness of three different surgical modalities in the treatment of implant-related infection. A total of 32 Wistar albino rats were randomised into four groups after the establishment of implant-related infection: no treatment, surgical débridement, antibiotic-loaded bone cement and antibiotic-loaded autogenous bone. Microbiological colony counts were made at the sixth week in order to evaluate the effectiveness of of the treatments. The antibiotic-loaded bone cement group revealed superior results compared with the other groups in terms of reduction of microbiological colonies. Three animals in the bone cement group revealed extensive infection. Although antibiotic-loaded bone cement showed superiority over other treatment modalities, it should be employed after an unsuccessful trial of débridement because of the risk of extensive infection.

Operative management of type III extension supracondylar fractures in children.

The purpose of this study was to compare primarily open versus primarily closed surgical treatment of Gartland type III extension supracondylar fractures in children. Also the outcomes of different pinning techniques in open surgery were evaluated retrospectively. Eighty displaced type III extension supracondylar fractures treated consecutively at two different centres were included. The treatment protocol of one institute was primarily closed reduction and percutaneous cross-pinning (n = 43). The treatment protocol of the other institute was primarily open reduction and internal fixation (n = 37) with two lateral parallel pins (n = 11), cross pins (n = 11) and two lateral and one medial pin (n = 15) according to the stability and configuration of the fracture. According to Flynn's criteria the outcomes of the open and closed reduction groups were not statistically significant (P > 0.05). Although the outcomes of closed reduction showed no superiority over open reduction, it should be the first choice of treatment due to its low morbidity and short hospital stay.