Investigation of the efficacy of epidermal growth factor, boric acid and their combination in cartilage injury in rats: An experimental study.

OBJECTIVES: In this study, we aimed to determine the bioefficacy of epidermal growth factor (EGF), boric acid (BA), and their combination on cartilage injury in rats. MATERIALS AND METHODS: In in vitro setting, the cytotoxic effects of BA, EGF, and their combinations using mouse fibroblast cell (L929), human bone osteosarcoma cell (Saos-2), and human adipose derived mesenchymal stem cells (hAD-MSCs) were determined by applying MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide] test. In in vivo setting, 72 rats were randomly divided into four groups. A standard chondral defect was created and microfracture was performed in all groups. Group A was determined as the control group. In addition to the standard procedure, Group B received 100 ng/mL of EGF, Group C received a combination of 100 ng/mL of EGF and 10 µg/mL of BA combination, and Group D 20 µg/mL of BA. RESULTS: The cytotoxic effect of the combinations of EGF dilutions (1, 5, 10, 25, 50, 100, 200 ng/mL) with BA (100, 300, 500 µg/mL) was observed only in the 72-h application period and in Saos-2. The cytotoxic effect of BA was reduced when combined with EGF. There was no significant difference in the histopathological scores among the groups (p=0.13). CONCLUSION: Our study showed that EGF and low-dose BA application had a positive effect on cartilage healing in rats. Significant decreases in recovery scores were observed in the other groups. The combination of EGF and BA promoted osteoblast growth. Detection of lytic lesions in the group treated with 20 µg/mL of BA indicates that BA may have a cytotoxic effect.

Is electromagnetic guidance system superior to a free-hand technique for distal locking in intramedullary nailing of tibial fractures? A prospective comparative study.

BACKGROUND: Intramedullary nailing (IMN) technique is the gold standard for the treatment of closed fractures of the lower extremity long bones. For orthopedic surgeons, one of the most important problems in IMN procedures is the fixation of distal locking screws (DLS). Accurate and rapid placement of DLSs with minimal radiation exposure is crucial. In this study, we aimed to compare the results of two different distal locking methods concerning surgery duration and radiation exposure in patients who underwent osteosynthesis of tibia fractures with IMN. METHODS: In this prospective study, the results of 56 patients who met the inclusion and exclusion criteria from 72 patients were evaluated. Patients were divided into two groups according to the distal screwing method. Group 1 (n=29) comprised patients who used free-hand technique (FHT) for distal locking, while Group 2 (n=27) consisted of patients who used electromagnetic guidance system (EMGS) for distal locking. Demographic and medical data of the patients, duration of surgery time, amount of bleeding, total fluoroscopy counts, the time elapsed for distal locking, the measure of radiation exposure, number of attempts for distal screw locking, incorrect screw placements, complications and follow-up time were recorded. The groups were compared concerning demographic data and clinical results. RESULTS: There was no statistically significant difference between the groups about gender and side (p=0.928 and p=0.432, respectively). The mean age in Group-1 was higher than that of Group-2, and the difference was statistically significant (p=0.012). However, there was no statistically significant difference in length of hospital stay in Group-1 (p=0.140). On the other hand, in Group-2, the number of distal shots, fluoroscopy duration, effective radiation dose and operation duration were lower compared to Group-1, although this difference was not statistically significant (p=0.057, 0.073, 0.058 and 0.056, respectively). Failure was encountered in distal locking during the first attempt in three cases in Group-1 and in two cases in Group-2. Aseptic nonunion was observed in one patient in both groups. CONCLUSION: Both the FHT distal screwing technique and the EMGS distal screwing technique are highly effective methods for distal locking. The duration of operation, the duration of the fluoroscopy and radiation exposure were similar. FHT can be preferred for distal locking in conventional intramedullary nail applications, as it is effective, easy and inexpensive.

Clinical, radiological and patient-reported outcomes in intra-articular calcaneal fractures: Comparison of conservative and surgical treatment.

OBJECTIVES: This study aims to compare the radiological, clinical and patient-reported outcomes of patients with intra-articular calcaneus fractures treated conservatively or surgically. PATIENTS AND METHODS: Fifty-four patients (30 males, 24 females; mean age 41.0 years; range, 18 to 73 years) treated due to calcaneus fracture were included in the study. Twenty-nine patients underwent conservative treatment (group 1) and 25 patients underwent surgical treatment (group 2). The fractures were classified according to Sanders. At the final follow-up, patients' Bohler's angle, The American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score and Foot Function Index (FFI) were used to evaluate their radiological, clinical and patient-reported outcomes. Postoperative complications were also noted. RESULTS: The fracture was at the right foot in 28 patients and the left foot in 26 patients. The mean follow-up duration was 41.1±23.2 months (range, 24 to 126 months). No statistically significant differences were found between the groups in terms of gender, fracture side, mean age, or follow-up duration (p=0.951, p=0.571, p=0.326, and p=0.620, respectively). According to Sanders classification, 18 patients were type 2 and 11 patients were type 3 in group 1, while 11 patients were type 2 and 14 patients were type 3 in group 2. However, there was no statistically significant difference between the groups in terms of the type of the fracture (p=0.184). On the other hand, the outcomes were significantly better for group 2 compared to group 1 in terms of the Bohler's angle, AOFAS and FFI scores (p=0.004, p=0.003 and p=0.006, respectively). In group 1, subtalar arthritis developed in three patients. In group 2, wound healing problems and superficial infection developed in three patients, while subtalar arthritis developed in two patients. CONCLUSION: Surgical treatment is more effective in intra-articular calcaneus fractures compared to conservative treatment according to clinical, radiological and patient-reported outcomes. In addition, wound problems should be considered in surgical management.

How is hip prosthesis and proximal femoral nail stability affected by lesser trochanter fractures: A comparative finite element analysis.

OBJECTIVES: This study aims to evaluate the effects of lesser trochanter (LT) and iliopsoas tendon on implant stability by using finite element analysis (FEA). MATERIALS AND METHODS: Effects of iliacus and psoas major muscles on hip joint was evaluated with inverse dynamics methods to calculate joint reaction and muscle forces. Intertrochanteric femur fracture was simulated according to AO (Arbeitsgemeinschaft für Osteosynthesefragen) 31A1 and 31A2 classifications in three-dimensional modelling software. Uncemented three-dimensional model of modular nail prosthesis combination was used in FEA. All analyses were performed with Ti6Al4V's 114 GPa elastic modulus value. Effects of LT on implant stability were evaluated with two different implant designs using the same femoral stems and four different femoral models, two of which with intact LT and two of which with fractured LT. RESULTS: Reaction forces of the hip joint decreased by 10% in the 0-40° hip flexion range. Maximum stress distribution for proximal femoral nail (PFN) model with fractured LT was 204.68 MPa at the distal locking screw on the interconnection point of PFN, while it was 335.35 MPa for the hip prosthesis with fractured LT. The direction of stress distribution for PFN model with fractured LT varied from medial to lateral and anterior to posterior. Maximum stress distribution for the hip prosthesis model with intact LT was 357.42 MPa, with direction of stress distribution from lateral to medial and posterior to anterior. CONCLUSION: Hip prosthesis models with intact or fractured LT were similar in terms of stress distribution and deformation values, while there were differences between PFN models with intact or fractured LT. Thus, intact LT was significant in PFN implant stability. Further clinical and experimental analyses are necessary on this topic.

Analysis of musculoskeletal dysmorphic abnormalities of 20 fetuses.

OBJECTIVES: This study aims to report rates of skeletal abnormalities and their risk factors in light of information obtained in a fetal autopsy series. PATIENTS AND METHODS: The study included 20 fetuses (11 males, 8 females and 1 ambiguous genitalia; mean age 19.3±4.0 weeks; range 16 to 32 week) who underwent autopsy in our hospital between January 2013 and March 2015. Fetuses were systematically classified according to age, gender, family history, abortus week, abortus type, and extremity and organ abnormalities. Skin biopsies were performed for genetic evaluation. Radiographic, pathologic and genetic findings were classified. RESULTS: Except one spontaneous abortus, all cases were applied medical abortus (94.1%). Genetic diagnosis could not be established in seven cases, whereas genetic disorders were identified in 13 cases: two trisomy 13, two trisomy 18, one (triploidi) 69,XXY, two arthrogryposis multiplex congenita, one osteogenesis imperfecta, one lethal multiple pterygium, one Saldino-Noonan syndrome, one teratogenic drug effect, one perinatal lethal hypophosphatasia, and one Beckwith-Wiedemann syndrome. Decreased fetal movement was one of the most frequently observed findings. Consanguineous marriage, oligohydramnios, drug addiction of the mother, teratogenic exposure, and other systemic abnormalities were risk factors. CONCLUSION: Skeletal dysplasias are rare diseases. Clinicians should be careful for skeletal abnormalities in perinatal period follow-ups.

Predictive factors for early hospital readmission and 1-year mortality in elder patients following surgical treatment of a hip fracture.

BACKGROUND: Early hospital readmission after surgically treated hip fracture is a common entity, often involving an adverse event and causing strains on an already overburdened healthcare system. The main purposes of the present study were to determine the 30-day readmission rate, analyze the predictive factors for early hospital readmissions, and assess 1-year mortality following surgical treatment of hip fracture in elderly patients. Retrospective case-control study. METHODS: In total, 517 patients with a mean age of 74 years were evaluated. The rate of early readmission, age, gender, body mass index, fracture type, pre-fracture mobility status, preoperative time to surgery, American Society of Anesthesiologists score, implant type, postoperative intensive care unit stay, total length of postoperative hospital stay, comorbidities, and the main reasons for readmission were the criteria for data collection. Multivariate analysis was performed to determine the main predictors of early hospital readmission. Mortality within the first year after surgery was also assessed. RESULTS: A higher prevalence of chronic obstructive pulmonary disease, cardiac arrhythmia or ischemic heart disease, diabetes, and dementia or Parkinson's disease was detected in readmitted patients. Advanced age, American Society of Anesthesiologists (ASA) grade ≥3, postoperative intensive care unit (ICU) stay, and pre-existing cardiac arrhythmia or ischemic heart disease were identified as the main predictors. The 1-year mortality rate for the readmitted group was 53.9%, whereas it was 24% for those patients who were not readmitted. CONCLUSION: The readmission rate following surgical treatment of hip fracture in elder patients was 12%, and its main predictive factors were advanced age, ASA grade ≥3, postoperative ICU stay, and pre-existing cardiac arrhythmia or ischemic heart disease. Hospital readmission within the first 30-day period following initial discharge was significantly correlated with an increased 1-year mortality rate.

Does Previous Hip Surgery Effect the Outcome of Tönnis Triple Periacetabular Osteotomy? Mid-Term Results.

Hip dysplasia (HD) is 1 of the major reasons of coxarthrosis. The goal of the treatment of HD by Tönnis triple pelvic osteotomy (TPAO) is to improve the function of hip joint while relieving pain, delaying and possibly preventing end-stage arthritis. The aim of this study is to compare the clinical and radiological results of TPAO to determine if previous surgery has a negative effect on TPAO.Patients operated with TPAO between 2005 and 2010, included in this study. Patients divided into 2 groups: primary acetabular dysplasia (PAD) and residual acetabular dysplasia (RAD). Prepostoperatively, hip range of motion, Harris hip score (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) hip score, visual analog scores (VAS), impingement tests, and also the presence of Trendelenburg sign (TS) were investigated for clinical evaluation. For radiological analysis pre-postoperative, anterior-posterior (AP) pelvis and faux profile radiographs were used. Acetabular index, lateral center edge (LCE) angle, and Sharp angles were measured by AP pelvis; anterior center edge (ACE) angle were measured by faux profile radiography. All the clinical and radiological data of the groups were analyzed separately for the pre-postoperative scores also the amount of improvement in all parameters were analyzed.SPSS20 (SPSS Inc., Chicago, IL) was used for statistical analysis. Wilcoxon test, McNemar test, paired t tests, and Mann-Whitney U tests were used to compare the groups. P < 0.05 were defined as statistically significant.Study included 27 patients: 17 patients were in PAD and 10 patients were in RAD. The mean follow-up period was 6.2 years (5.2-10.3 years). In all patients, the radiological and the clinical outcomes were better after TPAO except the flexion of the hip parameter. When the patient groups were evaluated as pre-postoperatively, more statistically significant parameters were found in the PAD group when compared with RAD group. Extension, impingement, TS, VAS, HHS, WOMAC score parameters in clinical outcome and LCE, ACE, Sharp angle, coverage ratio in radiological results were significantly better in PAD group postoperatively but in RAD group; only extension, VAS, HHS, and WOMAC parameters were clinically and LCE and Coverage ratio were significantly different compared with the preoperative measurements. The change of the parameters that used for the evaluation of clinical and radiological results did not show a significant difference between groups.Our data suggest that TPAO can be performed on patients with HD for both groups. Although there were fewer parameters which changed significantly after TPAO in RAD patients; the improvement of radiological and clinical results was similar for groups. Further long-term follow-up studies with large number of patients are needed to determine the proper results of TPAO.

A rare case of 3C disease: Ritscher-Schinzel syndrome presenting with recurrent talipes equinovarus.

INTRODUCTION: Club foot (CF) is characterized by multiple deformities such as varus, adductus and internal rotation of the forefoot. It is well-known and a frequent congenital disorder. CF can concurrently be seen with several diseases but it can rarely manifest as a component of any other syndrome. Ritscher-Schinzel syndrome, or cranio-cerebello-cardiac syndrome, is rarely seen and has autosomal recessive inheritance. It is characterized by cranio-facial, cerebellar and cardiac abnormalities. We report a case diagnosed as Ritscher-Schinzel syndrome concurrent with persistent CF. PRESENTATION OF CASE: A two-year-old boy with persistent CF and concurrent congenital hip dysplasia. Despite successful serial casting and subsequent achilloplasty a clinical relapse was observed in our patient. After a detailed phenotypic evaluation, genetical tests and imaging technique the patient was diagnosed 3C Ritscher-Schinzel syndrome. DISCUSSION: A comprehensive literature review did not show any reports about concurrent hip dysplasia and clubfoot in Ritscher-Schinzel syndrome. We report that CF may be associated with rare genetical abnormalities. CONCLUSION: With this report we would like to raise awareness about the possible association of persistent CF with this rare genetical disorder, Ritscher-Schinzel syndrome. It should be included in differential diagnosis of patients with persistent CF.

[A comparison of short-term clinical and radiological results of Tönnis and Steel pelvic osteotomies in patients with acetabular dysplasia]. / Asetabuler displazili hastalarda Tönnis ve Steel osteotomilerinin kisa dönem klinik ve radyolojik sonuçlarinin karsilastirilmasi

OBJECTIVES: This study aims to compare short-term clinical and radiological results of adult patients with acetabular dysplasia undergoing Tönnis osteotomy or Steel triple pelvic osteotomy. PATIENTS AND METHODS: Between March 2003 and January 2010, clinical and radiologic results in 61 patients who were operated due to acetabular dysplasia at Baltalimani Bone and Joint Diseases Hospital were retrospectively analyzed. The patients were divided into two groups including those undergoing Tönnis osteotomy (Tönnis group) or Steel osteotomy (Steel group). For each patient, anteroposterior and false-profile radiographs of the pelvis were taken and anterior center edge (ACE), lateral center edge (LCE), Sharp angles and acetabular coverage were measured. The relationship between femoral head and acetabulum was assessed. Harris hip score was used for the clinical evaluation. RESULTS: According to the evaluation of the clinical and radiological results, postoperative scores were improved significantly in both groups, compared to preoperative scores (p<0.01). No statistically significant difference was found between the groups in terms of improvements in the radiological and clinical scores, except ACE angle (p<0.01). CONCLUSION: Our study results suggest that Tönnis and Steel osteotomies offer satisfactory short-term results in the surgical treatment of adult patients with mild to moderate dysplasia.

Post-traumatic Median Nerve Neuroma in Wrist. A Case Report and brief review of Literature.

INTRODUCTION: Distal median nerve masses may be developed post-traumatic or non-traumatic. In this paper, we aim to present a 52 year old female case with a postraumatic neuroma of the median nerve in the left wrist. CASE SERIES: A 52-year-old female patient had accidental incised wound over her left wrist which was primarily sutured. She presented 6 months later with unrelieved pain and growing swelling at the wrist. USG showed solid mass of size 2x3 cms. Intraoperatively the mass was seen to arise from medial nerve and careful excision was done protecting the nerve. At one year follow up the patient is relived of her symptoms with no sensorimotor deficit. CONCLUSION: Post traumatic neuroma present as unrelieved pain and progressive swelling. A high index of suspicion should be kept in cases of wound that are primarily sutured over an area with superficial nerves. Careful excision of the lesion is very effective in relieving patients symptoms.

Single-stage treatment of complete dislocation of radial head and forearm deformity using distraction osteogenesis in paediatric patients having multiple cartilaginous exostosis.

BACKGROUND: We are reporting the results of single-stage treatment for patients with forearm deformity and radial head luxation due to hereditary multiple exostosis using distraction osteogenesis. METHOD: Six patients with a mean age of 12 years were treated. Morphological evaluation was made according to Masada (3 of the cases were 2a and 3; 2b). Angular deformities of forearm and wrist were evaluated as described by Fogel (distal radial joint angle was 27°, ulnar variance was 12.8 mm and carpal slip was 71.3%). Mean forearm pronation was 48.4° whilst mean supination was 19.2°. Mean elbow range of motion was 26.6°-103.4° and the mean DASH score was 75. Common surgical procedures were deformity correction, ulnar lengthening and gradual radial head reduction using external fixators. RESULTS: Mean follow-up period was 4.2 years and mean external fixation time was 6 months. Mean amount of ulnar lengthening was 2.9 cm and the distraction index was 14.9 cm/day. Mean radial articular angle was 14.3°, ulnar variance 2.3 mm, carpal slip 55%, forearm pronation 65.9° and supination was 55°. Mean elbow range of motion was 15.8°-119.2°. In the last follow-up, the mean value of DASH score was 8.1. Major and minor complications were seen during the follow ups. CONCLUSIONS: Single-stage deformity correction, ulnar lengthening and radial head reduction technique that we have used provide satisfactory functional and cosmetic results. Early surgical correction may lead to even better results.