Is elective cancer surgery feasible during the lock-down period of the COVID-19 pandemic? Analysis of a single institutional experience of 404 consecutive patients.

BACKGROUND: We aimed to assess the feasibility and short-term clinical outcomes of surgical procedures for cancer at an institution using a coronavirus disease 2019 (COVID-19)-free surgical pathway during the peak phase of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. MATERIALS AND METHODS: This was a single-center study, including cancer patients from all surgical departments, who underwent elective surgical procedures during the first peak phase between March 10 and June 30, 2020. The primary outcomes were the rate of postoperative SARS-CoV-2 infection and 30-day pulmonary or non-pulmonary related morbidity and mortality associated with SARS-CoV-2 disease. RESULTS: Four hundred and four cancer patients fulfilling inclusion criteria were analyzed. The rate of patients who underwent open and minimally invasive procedures was 61.9% and 38.1%, respectively. Only one (0.2%) patient died during the study period due to postoperative SARS-CoV2 infection because of acute respiratory distress syndrome. The overall non-SARS-CoV2 related 30-day morbidity and mortality rates were 19.3% and 1.7%, respectively; whereas the overall SARS-CoV2 related 30-day morbidity and mortality rates were 0.2% and 0.2%, respectively. CONCLUSIONS: Under strict institutional policies and measures to establish a COVID-19-free surgical pathway, elective and emergency cancer operations can be performed with acceptable perioperative and postoperative morbidity and mortality.

Cross-cultural adaptation and validation of the Turkish version of the Toronto Extremity Salvage Score in patients with musculoskeletal tumors.

OBJECTIVE: The aim of the study was to translate theToronto Extremity Salvage Score (TESS) into Turkish and perform acrosscultural adaptation for patients with musculoskeletal tumors. METHODS: Thirty-six patients (20 male, 16 female; mean age = 36.6 ± 15.4 years) who were diagnosed with malignant bone and soft tissue sarcoma or benign aggressive bone tumors between the years 2007 and 2012 were included in the study. TESS was translated into Turkish and back translated to determine language validity. To test convergent validity, the Turkish versions of the Short Form-36 (SF-36), Western Ontario and McMaster Universities Arthritis Index (WOMAC), and Disabilities of the Arm, Shoulder and Hand (DASH) were used. SF-36 was used on all patients while WOMAC and DASH were used onpatients with lower extremity tumors and upper extremity tumors respectively. The tests were repeated 15 days later and the intraclass correlation coefficient (ICC) was used to determine test-retest reliability. RESULTS: The Turkish version of TESS was found to have a strong negative correlation with WOMAC (r = -0.702; P < 0.001) and DASH (r = -0.774; P < 0.001) as well as a strong negative correlation with ROMS (r = 0.601; P < 0.001). Turkish TESS also had a statistically significant correlation with SF-36-Physical functioning, SF-36-Role Physical, SF-36-Bodily Pain, and SF36-General Health at levels ranging from 0.326 to 0.669 (r values ranging from 0.326 to 0.669, P < 0.001). The internal consistency (Cronbach's α:0.96 for lower extremity and Cronbach's α:0.94 for upper extremity) and test-retest reliability of Turkish TESS were found to be excellent (ICC lower extremity: 0.96 [0.935-0.983]; P < 0.001 and ICC upper extremity: 0.99 [0.967-0.997]; P < 001). ICC values varied between 0.674 and 0.987 for each item of the scale for both extremities. Conlusion: The Turkish version of TESS seems to be a valid and reliable patient-reported outcome measure to evaluate physical function after musculoskeletal tumor surgery in Turkish patients. LEVEL OF EVIDENCE: Level II, Diagnostic Study.

Cross-cultural adaptation and validation of the Turkish version of the Musculoskeletal Tumor Society scoring system in patients with musculoskeletal tumors.

OBJECTIVE: This study aimed to translate and cross-culturally adapt the musculoskeletal tumor society (MSTS) scoring system into Turkish and to determine the reliability and validity of the translated version for the functional evaluation of patients with musculoskeletal tumors. METHODS: A total of 36 patients (16 women, 20 men; mean age=36.6; age range=13-75 years) who underwent limb-salvage surgery owing to benign aggressive or malignant musculoskeletal tumors were included in the study. Translation and back translations of the MSTS were performed according to the published guidelines. Short form (SF) 36 physical component, Western Ontario and McMaster Universities Arthritis Index (WOMAC), disabilities of the arm, shoulder, and hand (DASH), and range of motion scale (ROMS) that were previously analyzed for Turkish validation were used for validity. Reliability of MSTS Turkish version was evaluated by calculating test-retest reliability and internal consistency. Intraclass correlation coefficient (ICC) was used to evaluate the inter-observer consistency and test-retest reliability. Alpha coefficient (Cronbach's alpha) was used to evaluate the internal consistency. RESULTS: It was observed that total MSTS score has a strong negative correlation with DASH (r=-0.689; p<0.001) and WOMAC scores (r=-0.634; p<0.001) and moderate correlation with the ROMS score (r=0.521; p<0.001). Total MSTS score also had a statistically significant strong correlation with SF-36 scores (r values ranging from 0.425 to 0.609, p<0.001). Inter and intra-observer reliability of the MSTS scale was found to be excellent (Cronbach's α=0.97 p<0.001; ICC: 0.97 (0.96-0.99; p<0.001). Unlike other subscales, statistical correlation between dexterity and hand-positioning subscales of MSTS with DASH scores was found to be insignificant (r=-0.533, p =0.061 and r=-0.336, p=0.261, respectively). CONCLUSION: The Turkish version of the MSTS scoring system seems to be a valid and reliable scale that measures the correct and desired values in the evaluation of health-related quality of life in orthopedic oncology. Reliability coefficients of the Turkish version of MSTS were determined to be strong. LEVEL OF EVIDENCE: Level II, Diagnostic Study.

[Pressure distribution patterns under the metatarsal heads in healthy individuals]. / Saglikli kisilerde metatars baslarinda dinamik basnç dagilim sekilleri.

OBJECTIVES: Recognition of plantar pressure distribution patterns of healthy individuals would be helpful in the management of metatarsalgia. We investigated plantar pressure distribution patterns under metatarsal heads in healthy individuals using the EMED-SF plantar pressure analysis system. METHODS: Plantar pressure measurements were performed in 106 healthy volunteers (45 females, 61 males; mean age 24 years; range 20 to 35 years) during walking on the EMED-SF platform. Footprints were divided into three areas based on the three functional columns of the tarsometatarsal joint, that is, the first metatarsal head, the second and third metatarsal heads, and the fourth and fifth metatarsal heads. The mean and peak pressures obtained in these areas were recorded. RESULTS: Pressure distribution patterns did not differ significantly between the two sexes and the right and left soles (p>0.05). The mean and peak pressures of the middle column during the mid-stance phase of the gait cycle were significantly higher than those recorded for the medial and lateral columns (p=0.000). There were no significant differences between the medial and lateral columns in this respect. At the pre-swing phase, pressures were significantly greater in the medial column compared to the lateral column. Four different patterns were noted with respect to the distribution of pressures among the three columns. Body mass index (BMI) was below the limit for obesity (<30 kg/m(2)) in all the participants. Peak pressure values obtained from each column at the pre-swing phase were significantly correlated with BMI (p<0.05); however, no correlation existed between the plantar pressures and BMI at the mid-stance phase (p>0.05). CONCLUSION: Our data show that there are four distinct pressure distribution patterns, but the greatest plantar pressure occurs in the middle column of the foot in the majority of healthy individuals.

[Venous thromboembolism prophylaxis in major orthopaedic surgery: A multicenter, prospective, observational study]. / Majör ortopedik cerrahilerde venöz tromboemboli profilaksisi: Cokmerkezli, prospektif, gözlem çalismasi.

OBJECTIVES: We investigated risk factors for venous thromboembolism (VTE), prophylaxis measures employed, and incidence of symptomatic deep venous thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing major orthopaedic surgery (MOS). METHODS: An open, multicenter, prospective, observational study was conducted in 21 medical centers, comprising 899 patients. Of these, 316 patients (35.2%) underwent total hip arthroplasty (THA), 328 patients (36.5%) underwent total knee arthroplasty (TKA), and 255 patients (28.4%) underwent surgery for hip fractures (HF). Pharmacologic prophylaxis was employed in all the patients. RESULTS: Risk factors for VTE were seen in 73.2% of the patients, the most common being obesity (72%) and prolonged immobilization (36.3%). Low-molecular-weight heparin (91.1%) and fondaparinux (8.9%) were used for prophylaxis, which was short-term in 273 patients (30.4%) and long-term in 626 patients (69.6%). Mechanical prophylaxis was performed with compression stockings in 610 patients (67.9%) and by intermittent pneumatic compression in 67 patients (7.5%). During three-months of follow-up, symptomatic DVT and PE were seen in eight (0.9%) and four patients (0.4%), respectively. Mortality occurred in 10 patients (1.1%). Complications of major and minor bleeding were seen in eight (0.9%) and 40 (4.5%) patients, respectively. CONCLUSION: Effective VTE prophylaxis is associated with low risk of clinically apparent DVT and PE in MOS.

Effect of synthetic cell-binding peptide on the healing of cortical segmental bone defects.

OBJECTIVE: To determine the effect of inorganic bone matric/Pepgen P-15 (ABM/P-15) on the healing of a critical sized segmental defect in a rat radius using a radiological and histological grading system. METHODS: We carried out this study at the Research Laboratories, Gazi University School of Medicine in 2004. Critical sized segmental defects were created in the radius of 36 Wistar rats. Thirteen defects were filled with ABM/P-15 Flow (gel form), 12 defects were filled with ABM/P-15, and 11 defects were used as a control group. The rats were sacrificed at the tenth week, and healing of the defects was evaluated radiographically and histologically. RESULTS: The usage of ABM/P-15 and ABM/P-15 Flow were demonstrated to improve healing of segmental bone defects compared with the control group. Statistical evaluation showed that there were significant differences between control sites, and the sites treated with P-15 and P-15 Flow (p=0.011). The highest radiological and histological grades were achieved by P-15. CONCLUSION: Segmental cortical bone defects may be treated with ABM/P-15 instead of bone allografts, and autografts. According to the radiological and histological parameters measured in this study, the implantation of ABM/P-15 resulted in optimum healing of the segmental cortical bone defects. Pepgen P-15 has a positive effect on bone healing, without any immunogenic features and disease transmission risk. Therefore, ABM/P-15 can also be used for orthopedic surgery.

Fate of bulk autografts in uncemented total hip arthroplasty. Evaluation by bone scintigraphy.

OBJECTIVE: To review short term results of uncemented cup implantation and the fate of bulk femoral head autografts in patients with acetabular bone deficiency due to dysplasia of the hip. We used bone scintigraphy to assess the viability of the grafts. METHODS: We treated 19 hip joints of 17 patients with osteoarthritis due to developmental dysplasia of the hip with uncemented total hip arthroplasty between 1997-2003 in the Department of Orthopedics and Traumatology, Gazi University, Ankara, Turkey. The average age was 49.1 (31-72 years), and the average follow up period was 36 months. We used femoral head autografts to reconstruct superolateral segmental deficiencies of the acetabuli. We evaluated the patients clinically and radiologically to assess acetabular loosening, and we used three-phase bone scintigraphy to evaluate the viability of the autograft. RESULTS: There was no acetabular component revision throughout the follow up period. There was no radiological evidence of graft resorption or graft displacement in any of the patients. In bone scintigraphy, we observed hyperemia in the blood pool phase, and the osteoblastic activity of the bone graft was at the level of the neighboring iliac bone. CONCLUSION: The application of a non-cemented acetabular component with femoral autograft in superolateral acetabulum deficiency increases the stability of the implant and increases the bone stock. It is not easy to evaluate the viability of the graft by the use of radiological methods. Bone scintigraphy gives sufficient information about the viability of the graft as a non-invasive method.

[Is there a correlation between severity of trauma and serum trace element levels?]. / Travma siddeti ile serum eser element düzeyi iliskili mi?

OBJECTIVES: Trace elements zinc and copper are effective in wound and fracture healing. In this prospective study, correlations between mangled extremity severity score (MESS) and mangled extremity syndrome index (MESI) and serum zinc and copper levels were investigated in trauma patients. METHODS: Seventeen trauma patients (11 females, 6 males; mean age 41.6 years; range 11 to 73 years) were evaluated with respect to MESS and MESI scores. On the seventh day of trauma, serum samples were obtained to determine zinc and copper levels by atomic absorption spectrophotometry. RESULTS: Serum levels of zinc and copper showed significant negative correlations with both MESS (r=-0.65 and r=-0.76, respectively) and MESI (r=-0.83 and r=-0.77, respectively) scores (p<0.05). CONCLUSION: The severity of trauma is associated with significant decreases in serum levels of trace elements. Thus, trace element supplementation may be an important aspect of treatment in trauma patients.

[Evaluation of the surgical results of Achilles tendon ruptures by gait analysis and isokinetic muscle strength measurements]. / Asil tendon yirtiklarinda cerrahi tedavi sonuçlarinin yürüme analizi ve kas gücü ölçümüyle degerlendirilmesi.

OBJECTIVES: We evaluated the long-term results of surgical treatment of Achilles tendon ruptures. METHODS: Fifteen male patients (mean age 39.5 years; range 28 to 58 years) underwent surgery for Achilles tendon ruptures. All the ruptures but one occurred during sport recreation. Eleven patients were treated within the first week of trauma. After surgery, a cast was applied for four weeks, after which it was switched to a polyethylene splint that did not allow dorsiflexion. Partial weight bearing was allowed in the fourth postoperative week. Subjective and objective evaluations were made according to the system by Thermann et al. Muscle strength was measured by an isokinetic dynamometer and gait analysis was performed. Data from the healthy sides were used for comparisons. The mean follow-up was 16.8 months (range 8 to 48 months). RESULTS: Seven patients (46.7%) had no pain, while six patients (40%), one patient (6.7%), and one patient complained of pain during heavy, medium, and light sports activities, respectively. Muscle strength did not decrease in nine patients (60%). Seven patients (46.7%) returned to preinjury activity levels. Twelve patients (80%) evaluated the outcome as very good or good. The mean muscle atrophy on the affected side was 0.43 cm. The overall results were very good or good in nine patients (60%), moderate in four patients (26.7%), and poor in two patients (13.3%). One patient had superficial infection and delayed healing. Isokinetic measurements showed decreased peak torque, and increased total work. By gait analysis, no significant relationship was found between the dorsiflexion and plantar flexion difference and forefoot ground reaction forces. CONCLUSION: Early surgical treatment of Achilles tendon ruptures followed by a shorter immobilization period is associated with satisfactory results, and in the long-term, with a higher rate of patient satisfaction.

[Anatomy, biomechanics, and pathophysiology of instability of the glenohumeral joint]. / Glenohumeral eklem instabilitesinin anatomik, biyomekanik ve patofizyolojik özellikleri.

The stability of the shoulder is dependent on both static and dynamic anatomic restraints. In most cases, there must be insufficiency of more than one restraint for the shoulder joint to become instable. Although the role of these restraints is largely known in maintaining shoulder stability, our information on their interactions is insufficient. This article reviews the anatomy and biomechanics of the shoulder and conditions causing instability of the glenohumeral joint.

[Open surgical treatment of recurrent anterior instability of the shoulder]. / Tekrarlayan anterior omuz instabilitesinin açik cerrahi tedavisi.

Recurrent anterior gleonohumeral instability is the most frequent joint instability of the body. Because of the complex stability mechanisms and diverse instability patterns of the glenohumeral joint, most cases present with more than one anatomic cause. Thus, the treatment of recurrent anterior instability of the shoulder should be designed to treat these pathologies. Although arthroscopic repair has outweighed the use of open surgical methods especially for the first dislocations, recurrent dislocations still require open repair techniques to overcome capsular laxity accompanying a Bankart lesion.

Effect of strontium ranelate on hydrogen peroxide-induced apoptosis of CRL-11372 cells.

In vitro and in vivo studies have proven strontium to be an osteoinductive trace element. The effect of strontium ranelate (SR) on H(2)O(2)-induced apoptosis of CRL-11372 cells and optimization of its anti-apoptotic dose were the aims of this study. After 1 h of pretreatment with SR 1 microM, 50 microM, 100 microM, 500 microM, and 1,000 microM concentrations, CRL-11372 osteoblasts were exposed to 100 microM H(2)O(2) for periods of 6-12 h. The same experiments were repeated without H(2)O(2). The apoptotic index and viability of cells were assessed quantitatively with a fluorescent dye and qualitatively with agarose gel electrophoresis. Concentrations of 1-100 microM of SR with a 6-h treatment and only 1 microM concentration with a 12-h treatment inhibited the apoptotic effect of H(2)O(2) on cultured osteoblasts significantly (P < 0.05). SR was shown to inhibit H(2)O(2)-induced apoptosis of CRL-11372 cells in a dose-dependent manner.

What leads to unfavourable Cybex test results for quadriceps power after modified tension band osteosynthesis of patellar fractures?

This study recruited 20 patients who had undergone modified tension band wiring for patellar fracture, with a mean follow up of 30 months. Subjects were grouped according to results of Cybex isokinetic testing at 60 degrees /s angular velocity. Subjects with <30% deficit as compared with the contralateral knee constituted group I, and those with >30% similar deficit formed group II. Plain radiography and HSS scoring were also performed. According to patient satisfaction, HSS scoring and Cybex testing, results were good in 80%, 90% and 55% of cases, respectively. Statistical analysis revealed that there were no significant differences between the two groups in terms of age, gender, duration of follow up, fracture type (two-part or comminuted), dominancy, time interval between trauma and surgery, or duration of immobilisation. The number of patients with >1 mm articular incongruity postoperatively was significantly higher in group II, which also had significantly higher incidences of >1 cm thigh atrophy and pain and thus increased deficits. We suggest that articular incongruity should be limited strictly to 1mm in surgery for patellar fractures.

Clear cell chondrosarcoma of the proximal femur with intrapelvic extension.

Clear cell chondrosarcoma is a rare tumor that can be easily confused with benign tumors. The aim of this report is to present a case that is rare, initially diagnosed as aneurysmal bone cyst and then chondroblastoma, and has an interesting extension pattern. A 41-year-old male patient was treated for an apparently benign cystic lesion of the right proximal femur by intralesional excision and bone grafting. The pathological diagnosis was aneurysmal bone cyst. Two years later, the patient presented with a pathological fracture at the same site and a total hip arthroplasty was performed. The pathological specimen was diagnosed as chondroblastoma. Three years later, clinical and radiological examination of the patient revealed a large mass located on the intrapelvic side of the acetabulum. There was no evidence of distant metastases. Both tumors were resected with a wide margin on the femoral side and a marginal margin on the intrapelvic side. The extremity was reconstructed with a resection-type total hip prosthesis. Again, the pathological diagnosis was chondroblastoma. The patient developed a deep infection that was treated by antibiotic therapy and surgical debridement. One year later, there was recurrence of the femoral and intrapelvic masses and right hemipelvectomy was performed; the specimen was reported as clear cell chondrosarcoma. Since then, the patient has been leading an active life, and there is no evidence of local recurrence or distant metastasis. Clinically and pathologically, clear cell chondrosarcoma may be confused with benign bone tumors. This caused a delay in the final diagnosis of this patient and he received inadequate surgical treatment, leading to a hemipelvectomy. We also found that the intrapelvic mass seemed to have developed independently on the intrapelvic side of the acetabulum. We were unable to find an exact explanation for this finding and postulated that tumor cells might have been seeded into the inner wall of the acetabulum during acetabular preparation of the total hip prosthesis.

Modified and classic acromioplasty for impingement of the shoulder.

We compared the results of modified and classic anterior acromioplasty in order to identify the significance of the resected acromion. Fifty patients with shoulder impingement syndrome resistant to conservative therapy underwent surgical treatment. We treated 30 patients with classic Neer acromioplasty (group 1), and 20 patients with modified Neer acromioplasty (group 2). The patients were assessed according to pain and shoulder movement. Excellent or good results were achieved in 28/30 patients in group I and 19/20 patients in group 2. The results indicate that both surgical techniques are effective procedures in the treatment of shoulder impingement syndrome, and the type of bone resection does not influence the clinical outcome.