Prosthesis applications and challenges in children with earthquake-related amputations.

BACKGROUND: Amputations are among the most important traumatic injuries caused by earthquakes. However, data on amputee children and prosthesis application is quite limited in the literature. The aim of the study is to evaluate the injury-related data, stump problems, prosthesis application, difficulties and complications experienced with prosthesis during follow-up of children with 2023 Kahramanmaras earthquake-related limb loss. PATIENTS AND METHODS: Sociodemographic and injury-related data, pre-amputation and post-amputation interventions, prosthesis application, current prosthetic problems, and revision surgeries of the amputee children were recorded. RESULTS: Median age of patients (n = 102) admitted to our center was 13.0 years. 67.6 % of patients had one or more concomitant injuries. Median time and number of amputations were 4 (0-57) days and 1 (1-4), respectively. Of the total 120 amputations, 67.5 % (n = 81) were lower extremity amputations. Most common amputation levels were transtibial (29.1 %, n = 35), transfemoral (22.5 %, n = 27), and transhumeral (15.8 %, n = 19). Most amputees (56.8 %) underwent revision surgery after initial amputation. Median duration of time from amputation to prosthesis application was 184 (28-314) days. For 25 prostheses, a socket revision was required. Six patients had surgical revision of the stumps to allow prosthetic fit and mobility (due to bone overgrowth, soft tissue failure, heterotopic ossification). CONCLUSION: Limited healthcare facilities, surgeries performed under emergency conditions, accompanying multiple traumas, inadequate follow-up conditions, and additional difficulties arising from the pediatric patient group lead to difficulties in the care of pediatric amputee patients. Our results will guide the care of this vulnerable patient population in the event of a similar unfortunate disaster.

6 February 2023, orthopedic experience in Kahramanmaras earthquake and surgical decision in patients with crush syndrome.

BACKGROUND: The decision of fasciotomy or amputation in crush syndrome is controversial and challenging for surgeons. We aimed to share our experiences after the Kahramanmaras earthquake, to predict the severity of crush syndrome and mortality, and to guide the surgical decision. METHODS: The clinical data of patients during their first week of hospitalization were analyzed retrospectively. Totally, 233 crush syndrome patients were included. Demographic data, physical and laboratory findings, surgical treatments, and outcomes were recorded. RESULTS: The mean time under the rubble was 41.89 ± 29.75 h. Fasciotomy and amputation were performed in 41 (17.6%) and 72 (30.9%) patients. One hundred and two patients (56.7%) underwent hemodialysis. Fifteen patients (6.4%) died. Lower extremity injury, abdominal trauma, and thoracic trauma were associated with mortality. Mortality was significantly increased in patients with thigh injuries (p = 0.028). The mean peak CK concentration was 69.817.69 ± 134.812.04 U/L. Peak CK concentration increased substantially with amputation (p = 0.002), lower limb injury (p < 0.001), abdominal trauma (p = 0.011), and thoracic trauma (p = 0.048). CONCLUSIONS: Thigh injury is associated with the severity of crush syndrome and mortality. Late fasciotomy should not be preferred in crush syndrome. Amputation is life-saving, especially in desperate lower extremity injuries.

Reconstruction of critical size segmental femoral diaphyseal defects of New Zealand rabbits by using combined titanium mesh cage and induced membrane technique.

PURPOSE: Long bone defects due to fractures resulting from high-energy trauma, infections and tumor resections are problems that orthopedic surgeons commonly face. We investigated the effects of a titanium mesh cage on bone healing with an induced membrane technique. METHODS: Three groups, each composed of eight rabbits, were formed. Extraarticular diaphyseal bone defects were created. Femora of the first group were fixed with an empty titanium mesh cage and two K-wires. After formation of the defect, polymethylmethacrylate was inserted and fixed with a K-wire in the second group. At the third week, the cement was removed, a sterilized cancellous graft-filled titanium mesh cage was placed into the defect, and the membrane that was previously formed over the cement was placed on the cage and repaired. In the third group, sterilized cancellous grafts were filled into the titanium mesh cage, and the titanium mesh cage was fitted into the bone defect area. RESULTS: At the end of the third month, all subjects were killed. Radiological data revealed that the healing of the bone in the second and third groups was significantly better than that in the first group. There was no difference between the second and third groups. A histological evaluation of the healing status, such as fibrous tissue, cartilage tissue and mature or immature bone formation, was performed. Histological healing in the second and third groups was also significantly better than that in the first group. CONCLUSION: We concluded that the combination of membrane-induced bone healing and graft-filled titanium mesh cages expedites osteogenesis in extraarticular bone defects.

Evaluation of Thirst in the Early Postoperative Period in Patients Undergoing Orthopedic Surgery.

BACKGROUND: Thirst, is a subjective symptom that has a high incidence in the early postoperative period and causes patients to experience intense discomfort. PURPOSE: The aim of this study is to determine thirst and the factors affecting thirst in the early postoperative period in patients undergoing orthopedic surgery. DESIGN: The research was carried out as a descriptive-cross sectional study with 177 patients between September 2021 and January 2022. METHODS: Data were collected using the "Descriptive and clinical features form," "Thirst and Symptoms Associated with Thirst Evaluation Form." For descriptive analysis, frequency, percentage distribution, mean, and minimum-maximum values were analyzed. The Chi-square test was used to compare the data according to the groups. Before starting the research, necessary ethics committee and institutional permission were obtained. FINDINGS: The mean perioperative thirst time of the patients was 15.25 ± 3.61 hours and the mean anesthesia time was 2.32 ± 1.13 hours. When the perioperative thirst duration was compared with the type of surgery, duration of operation, type of anesthesia, duration of anesthesia, duration of fasting, intubation and duration of stay in PACU, there was a statistical significance between them (P > .05). CONCLUSIONS: The most common symptoms in patients undergoing orthopedic surgery were thirst and dry mouth. Surgery type, operation duration, anesthesia type, anesthesia duration, fasting duration, intubation status and duration of stay in PACU were the factors affecting the perioperative thirst status of the patients.

Clinical and radiological outcomes of Salter versus Pemberton osteotomies in the management of developmental dysplasia of the hip: A retrospective comparative study.

OBJECTIVE: The aim of this study was to investigate whether there is a relationship between Salter and Pemberton pelvic osteotomies and avascular necrosis of femoral head in the management of developmental dysplasia of the hip (DDH). METHODS: This retrospective study included 69 hips of 52 patients aged between 12-36 months, diagnosed as DDH who had undergone either Salter or Pemberton pelvic osteotomy with Smith Petersen approach. There were 35 patients in Salter Pelvic Osteotomy and 34 patients in Pemberton Pelvic Osteotomy groups. Before the treatment of DDH, Tönnis classification was used, preoperative and 24th month postoperative Acetabular Index (AI) angles were measured. Kalamchi-MacEwen grades of avascular necrosis were determined in terms of presence of avascular necrosis of the femoral head. RESULTS: There were no significant differences between two osteotomy groups at the end of mid-term follow up in terms of the radiological parameters and avascular necrosis of femoral head. However it was found that the increased avascular necrosis incidence was significantly associated with Tönnis grade 4 hips. CONCLUSION: Salter and Pemberton osteotomies can be both used safely in the treatment of DDH regarding their effect on the femoral head. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

The histological effect of tranexamic acid on tendon-to-bone healing histologically in rats.

OBJECTIVES: In this study, we aimed to investigate the effect of tranexamic acid (TXA) on osteotendinous junction healing in a rat model, both biomechanically and histologically. MATERIALS AND METHODS: Sixty-four male Wistar-Albino rats weighing 450 to 600 g were used in this study. The rats were divided into two groups as the experimental (n=16) and control (n=16) groups. Achillotomy and subsequent repair site was exposed to 1 mL of TXA in the experimental group, while 1 mL of saline was given to the control group. For biomechanical and histopathological investigation, each group was further divided into two subgroups. At the end of four weeks, all rats were sacrificed. Biomechanical tests were performed using the M500-50CT device. The Bonar, Movin, and Nourissat bone-tendon junction scoring systems were used for histopathological evaluation. RESULTS: There was no statistically significant difference in the elongation at a maximum point, maximum loading, and maximum stress variables in the biomechanical study (p=0.558 p=0.775, and p=0.558, respectively). In the histopathological evaluation, the collagen content and layout were close to the native tissue in the experimental group (p=0.047 and p=0.008, respectively). Vascularity, hyalinization, and glycosaminoglycan content were significantly lower in the experimental group (p=0.004, p=0.014, and p=0.026, respectively). The total Bonar and Movin scores were more favorable in the experimental group (p<0.001). CONCLUSION: This experimental study showed that local administration of TXA accelerated bone-tendon junction healing in rats.

Association between phantom limb complex and the level of amputation in lower limb amputee.

OBJECTIVE: The aim of this study was to evaluate the natural course of phantom limb complex without any treatment after lower limb amputation. METHODS: The study design was consisted of a combination of retrospective review and cross-sectional interview. 101 patients with lower limb amputation were included into the study. Patients were divided into three groups according to the amputation level: i) from hip disarticulation to knee disarticulation (including knee disarticulation) (25 patients, mean age: 55.9, 19 males, 6 females) ii) transtibial amputation (below knee to ankle including ankle disarticulation) (41 patients, mean age: 58.6, 33 males, 8 females) iii) below ankle to toe amputation (35 patients, mean age: 58.7, 26 males, 9 females). The patients were evaluated on both early postoperative period (EPP) and sixth months after the surgery (ASM). The data related amputation including amputation date, level, cause, stump pain (SP), phantom limb pain (PLP), components of PLP, phantom sensation (PS) were recorded based on the information obtained from patients' and hospital files. RESULTS: Statistically significant differences were found for pain intensity (VAS) between groups for SP and PLP at EPP (p < 0.001, p = 0.036; respectively). The mean VAS score in Group I for SP and PLP was higher than other groups. This differences for SP and PLP did not continue at ASM assessment (p = 0.242, p = 0.580; respectively). CONCLUSION: VAS scores for SP in above knee amputations and VAS scores for PLP in above knee amputations and below ankle amputations were higher at EPP. But these high scores had disappeared over time. Management strategies have to be considered particularly in the early postoperative period in patients who had undergone above knee amputation. LEVEL OF EVIDENCE: Level III Prognostic study.

Elastofibroma dorsi: Clinical evaluation of 61 cases and review of the literature.

OBJECTIVE: Elastofibroma dorsi (ED) is a rare, benign, soft tissue tumor typically located between inferior corner of scapula and posterior chest wall causing mass, scapular snapping, and pain. When classic symptoms and localization are present, it is diagnosed without biopsy and treated with marginal resection. This study retrospectively analyzed patients operated on for ED to evaluate presenting symptoms, tumor size, complications, and clinical results, and to suggest optimal treatments. METHODS: This study included 51 patients who underwent surgery for ED in 2 different clinics between 2005 and 2015. Patient age, gender, profession, side affected, symptoms, average duration of symptoms, and tumor size were researched. Radiological examinations of patients were evaluated. Patients with lesions larger than 5 cm in size were operated on. Postoperative complications, recurrence, and functional results were evaluated using Constant score and compared to preoperative values. RESULTS: A total of 61 operated lesions of 51 patients clinically and radiologically diagnosed with ED were retrospectively evaluated. Average length of time patient experienced symptoms was 11.21 months. Lesions in 19 (37.2%) patients were bilateral, 10 of which were symptomatic and larger than 5 cm in size, meeting indication for surgery. Average lesion diameter was 8.7 cm. Average follow-up was 26.89 months. Average of preoperative Constant score of 67.28 subsequently increased to 92.88 (p < 0.05). Seroma and hematoma were observed in 11.5% of patients. CONCLUSION: Generally, good clinical results can be obtained with marginal resection without requiring a biopsy, considering classic complaints and radiological appearance of ED. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Treatment of post-traumatic elbow deformities in children with the Ilizarov distraction osteogenesis technique.

OBJECTIVE: The present study assessed functional and radiographic outcomes of distraction osteogenesis treatment of post-traumatic elbow deformities in children. METHODS: Eight children were treated between 2008 and 2013 for post-traumatic elbow deformities using distraction osteogenesis. Mean age at time of operation was 10.9 years. Six patients had varus and 2 had valgus deformity. Magnitude of correction, fixator index, complications, carrying angle, and elbow range of motion were assessed. Functional results were graded according to protocol of Bellemore et al. RESULTS: Mean follow-up was 43 months. Mean preoperative varus deformity in 6 patients was 29.2° and valgus deformity in 2 patients was 28.5°. Preoperative flexion and extension of elbow were 123.8° and -10.6°, respectively. Mean carrying angle was 9° valgus at last follow-up. Mean flexion and extension were 134.4° and -6.0°, respectively. Change in carrying angle was statistically significant (p = 0.002). There were 2 grade 1 pin tract infections and 1 diaphyseal fracture of humerus. Functional outcome was rated excellent in 7 patients and good in 1 patient. CONCLUSION: Ilizarov distraction osteogenesis is a valuable alternative in treatment of elbow deformities in children. The surgical technique is simple and correction is adjustable. Gradual correction prevents possible neurovascular complications and minimally invasive surgery produces less scarring. Compliance of patient and family is key factor in the success of the outcome. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Clinical and pathological results of denosumab treatment for giant cell tumors of bone: Prospective study of 14 cases.

OBJECTIVE: Giant cell tumor of bone (GCT) is a primary, osteolytic, benign tumor of the bone. Surgery is the commonly used treatment; however, recurrence remains a problem. Receptor activator of nuclear factor kappa B (RANKL) is responsible for the formation of osteoclastic cells. Discovery of RANKL and its human monoclonal antibody, denosumab, led to use of denosumab for treatment of GCT. The aim of this study was to evaluate clinical and pathological results of treatment of GCT with denosumab and to assess adverse effect profile and recurrence rate. METHODS: Thirteen patients with 14 lesions were enrolled in the study. Mean age was 38.3 years. Patients were given subcutaneous injections of denosumab (120 mg) every 4 weeks (with additional doses on days 0, 8 and 15 in cycle 1 only) and were radiologically evaluated for tumor response. Pain and functional status were measured using Visual Analog Score (VAS) and Musculoskeletal Tumor Society Score (MSTS). Adverse effects were analyzed after each cycle. RESULTS: Participants were 5 men and 8 women. Mean follow-up was 17 months. One lesion was Campanacci grade I, 8 were grade II, and 5 were grade III. Eight lesions were recurrent, and remaining were primary lesions. After average of 9 cycles (range: 4-17 cycles), all tumors underwent radiological regression. Ten lesions were removed surgically. More than 90% of giant cells were found to have regressed in all pathological specimens. On last follow-up, average VAS was 1 and MSTS was 87%. Fatigue and joint and muscle pain after injections was reported by 46% of patients, and mild hypocalcaemia was seen in 1 patient. CONCLUSION: Denosumab has been shown to be a successful drug in treatment of GCT. Denosumab can be used as neoadjuvant for all recurrent lesions, grade II lesions with high surgical risk, grade III lesions, and metastatic cases of GCT. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Humeral surface anatomy and percutaneous plate advancement: a cadaveric study.

OBJECTIVE: The aim of this study was to identify the anatomical obstacles on the humeral surface which can complicate subcutaneous plate advancement during surgical treatment of humeral fractures. METHODS: We dissected twelve upper extremities of six male cadavers, and measured the humeral length, which was defined as the distance between the greater tubercle and the lateral epicondyle. We performed a retrograde advancement of a 4.5 mm plate through the subbrachial tunnel and noted the mechanical obstacles during the procedure. In addition, we recorded the distances between the anatomic obstacles and lateral epicondyle. RESULTS: The average humeral length was 271.8 mm. We identified anterior insertion of the deltoid muscle and the proximal part of the brachialis muscle as the main anatomic obstacles on the anterior surface of the humerus. The average distances between the lateral epicondyle and the most proximal and distal insertion of anterior deltoid were 188.9 mm and 138.7 mm, respectively. The average distance between the lateral epicondyle and the brachialis origin was 147.4 mm. Proportions of the distances between the lateral epicondyle and proximal of anterior deltoid insertion, the lateral epicondyle and distal of anterior deltoid insertion and the lateral epicondyle and proximal of brachialis origin to humeral length were 69.4%, 51%, and 54.2%, respectively. There was a high interobserver reliability (p<0.001). CONCLUSION: The deltoid insertion and proximal attachment of the brachialis muscles were identified as mechanical obstacles when performing the percutaneous plating. These sites caused difficulties with the procedure during the retrograde plate advancement through submuscular tunnel on the anterior surface of humerus. It was also noted that for successful plate advancement, it was necessary to release the anterior part of the deltoid insertion.

Clinical characterization of unusual cystic echinococcosis in southern part of Turkey.

BACKGROUND AND OBJECTIVES: The incidence of primary extrahepatic cystic echinococcosis (CE) is rare. Generally, radiological and serological findings can help establish the diagnosis of hepatic and pulmonary CE, but a CE in an unusual location with atypical radiological findings may complicate the differential diagnosis. The objective of this study is to present the characteristics of cases with extrahepatic CE in respect of sites of involvement, clinical presentations, radiological findings, serological diagnostic evaluations, and outcomes of infected patients. DESIGN AND SETTINGS: A retrospective analysis of surgically treated CE was conducted between January 1993 and January 2014 in the General Surgery, Pediatric Surgery, Urology, Cardiovascular Surgery, Neurosurgery, and Orthopedics departments of University of Cukurova, Faculty of Medicine, Balcal Hospital. PATIENTS AND METHODS: Among the 661 patients managed for CE, 134 had unusual sites of involvement. Radiological and serological examinations were used to differentiate CE from alveolar echinococcosis. RESULTS: Of 134 cases with unusual sites of involvement, 32 cases had liver CE (23.9%), 7 cases had lung CE (5.2%), and 2 cases had concomitant liver and lung CE (1.5%). In 93 (69.4%) cases, unusual organ involvement was isolated without any liver or lung involvement. The mean age was 45 years. Abdominal pain was the main symptom and was found in 104 patients. Thirty-one (23.1%) of 134 extrahepatic CE cases were evaluated as negative with indirect hemagglutination (IHA). However, positive results were obtained in 54 cases evaluated with Echinococcus granulosus IgG Western blot (WB), including 10 IHA-negative cases. CONCLUSION: CE with unusual localizations may cause serious problems of diagnostic confusion. The combination of clinical history, radiological findings, and serological test results (especially the WB) are valuable in diagnosing extrahepatic CE.

A novel repair method for the treatment of acute Achilles tendon rupture with minimally invasive approach using button implant: a biomechanical study.

BACKGROUND: Minimally invasive Q3 repair has been proposed for acute Achilles tendon rupture with low rate of complications. However there are still controversies about optimal technique. In this study we aimed to describe Endobutton-assisted modified Bunnell configuration as a new Achilles tendon repair technique and evaluate its biomechanical properties comparing with native tendon and Krackow technique. METHODS: 27 ovine Achilles tendons were obtained and randomly placed into 3 groups with 9 specimens ineach. The Achilles tendons were repaired with Endobutton-assisted modified Bunnell technique in group 1, Krackow suture technique in group 2 and group 3 was defined as the control group including native tendons. Unidirectional tensile loading to failure was performed at 25mm/min. Biomechanicalproperties such as peak force to failure (N), stress at peak (MPa), elongation at failure, and Young'smodulus (GPa) was measured for each group. All groups were compared with each other using one-wayANOVA followed by the Tukey HSD multiple comparison test (a=0.05). RESULTS: The average peak force (N) to failure of group 1 and group 2 and control group was 415.6±57.6, 268.1±65.2 and 704.5±85.8, respectively. There was no statistically significant difference between native tendon and group 1 for the amount elongation at failure (p>0.05). CONCLUSIONS: Regarding the results, we concluded that Endobutton-assisted modified Bunnell technique provides stronger fixation than conventional techniques. It may allow early range of motion and can be easily applied in minimally invasive and percutaneous methods particularly for cases with poor quality tendon at the distal part of rupture. LEVEL OF EVIDENCE: Level II, Biomechanical research study.

Unusual cause of knee locking.

We report a case of partial intrasubstance tear of popliteus tendon as an unusual cause of pseudolocking of the knee. A 13-year-old semiprofessional soccer player applied to our clinic with a locked right knee in spite of the therapy applied (cold pack, NSAID, and immobilization) in another institution 20 days after the injury. Significant extension loss was observed in his right knee with 30°-90° ROM. Magnetic resonance imaging (MRI) and arthroscopy confirmed the intrasubstance tear of popliteus tendon and synovitis. The ruptured part of the tendon was debrided, and the inflammatory tissue around the tendon, which may lead to pseudolocking, was gently removed with a shaver in order to regain the normal ROM. The patient was discharged with full ROM and weight bearing first day after the surgery. To our knowledge, this is the first case demonstrating intrasubstance tear of popliteus tendon causing pseudolocking of the knee.