Pectoralis major pedicle bone grafting vs. tricortical iliac grafting for Neer 4-part proximal humerus fractures: a randomized controlled trial.

BACKGROUND: The risk of avascular necrosis, nonunion, or malunion is high in osteoporosis-related 4-part fractures. We evaluated the results of patients who underwent plate osteosynthesis with a vascularized pectoralis major graft compared with tricortical iliac grafting to treat 4-part proximal humerus fractures. MATERIAL AND METHODS: Thirty-four patients aged 50-75 years with Neer 4-part proximal humerus fractures were studied. Group A (n = 17) underwent osteotomy of a 2.5 ± 1 cm pectoralis major pedicle bone graft and plate application, whereas group B (n = 17) underwent plate osteosynthesis using iliac autogenous grafts. Final follow-up assessments included evaluation using Constant and American Shoulder and Elbow Surgeons scoring systems, humeral neck-shaft angle (HNSA), humeral head height, and humeral head avascular necrosis. RESULTS: Reduction loss was observed in 3 patients (17.6%) in group A, whereas it was observed in 10 patients (58.8%) in group B (P = .013). Humeral head avascular necrosis was found in 1 patient (5.8%) in group A, whereas it was found in 5 patients (29.4%) in the other group (P = .071). The HNSA was normal in 12 (70.5%) of group A patients, whereas it was normal in 6 (35.2%) of group B patients. The HNSA was weak or bad (<1200) in 29.4% of group A patients, whereas this rate was 64.7% in group B patients. Humeral head height was 2.64 ± 1.45 mm in group A and 3.66 ± 1.65 mm in group B. There were no statistically significant differences between the 2 groups in terms of Constant and American Shoulder and Elbow Surgeons scoring systems. CONCLUSION: Pectoralis major bone pedicle graft in Neer 4-part proximal humerus fractures reduces the risk of avascular necrosis and nonunion rates. Our technique yielded excellent clinical and radiological results. We achieved recovery without creating additional donor site morbidity.

Does forearm position matter in subpectoral biceps tenodesis? A randomised controlled trial.

INTRODUCTION: The optimal position of the elbow and forearm during biceps tenodesis is a debated topic. The aim of our study was to compare two different forearm positions, pronation-extension (PE) or neutral, for fixation of the long head of the biceps tendon (LHB) in biceps tenodesis. MATERIALS AND METHODS: Fifty patients who underwent shoulder arthroscopy between February 2016 and January 2019 were included in our study. After diagnostic arthroscopy, the LHB was cut from its origin with a thermal ablator. The LHB was then tenodesed beneath the inferior border of the pectoralis major tendon for 25 patients in the PE position and for 25 patients in the neutral position. Patients were evaluated preoperatively and 3rd, 6th and 12th months postoperatively according to the visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) shoulder and Constant scores. Flexion and supination force measurements were made with a digital dynamometer device, compared to the healthy side for both groups. RESULTS: ASES and VAS scores were statistically better in the PE group compared with the neutral group (p < 0.05), but there was no statistically significant difference between Constant scores at 3 and 6 months (p > 0.05). No significant difference was found in both groups for 3 scores at 12 months. Comparison of the PE group with the contralateral extremity and comparing the neutral group with the contralateral extremity in terms of flexion strength showed no statistically significant difference. No statistically significant difference was found between the supination powers of both comparative groups. CONCLUSION: Functional scoring in the PE position is better at 3 and 6 months because patients experience less pain at 3 and 6 months. The simple change of the fixation position causes patients to feel less pain in the early period.

Approach to Displaced Intra-Articular Calcaneus Fractures After Attempted Suicide Among Patients With Psychiatric Disorders: Nonsurgical or Surgical?

Displaced intra-articular calcaneus fracture is one of the injurious events in psychiatric patients after high-jump suicide attempts. These patients are reported to have poorer compliance and worse postoperative outcomes compared to those with no psychiatric condition.  We aimed to compare nonsurgical and surgical treatment with respect to functional and radiological outcomes and complications in this patient. We evaluated medical records of 42 psychiatric patients who had displaced intra-articular calcaneal fractures after high-jump suicide attempt. 20 (54%) of these were treated nonsurgically and further 17 patients (46%) received surgical intervention. We compared to nonsurgical and surgical approaches statistically. The mean follow-up period were 30.4 ± 8.02 months and 31.8 ± 7.5 months in the nonsurgical and surgical groups, respectively. Böhler's angle was significantly higher in the surgical group (30.4 ± 6.4) than that in the nonsurgical group (16.1 ± 3.7) (p = .001). AOFAS scores and supination levels were significantly higher in the surgical group than that in the nonsurgical group (p ≤ .05). During the follow-up period, one patient from the surgical group re-attempted high-jump suicide and died, and another one caused the subtalar joint to re-collapse after full weightbearing on the first postoperative day. Surgical treatment of displaced intra-articular calcaneal fractures following a high-jump suicide attempt in psychiatric patients may not cause increased complication rates. However, behavioral manifestations of the psychiatric disorder might be associated with several complications. Should any surgical intervention be decided, minimal invasive approach would be the appropriate choice.

The Effect of Syndesmotic Screw Level on Postoperative Syndesmosis Malreduction.

Tibiofibular injury repair of ankle fractures may result in over-compression when performed via a partially threaded screw depending on its placed level. We aimed to examine the relationship between the screw level relative to the tibiotalar joint and syndesmosis malreduction in postoperative radiographs of ankle fractures treated with partially threaded screws. We retrospectively analyzed 129 patients who underwent surgery due to lateral malleolar fractures between 2011 and 2019. We measured the distance between the screw and the tibiotalar joint and stratified the patients per their screw level as either trans-syndesmotic or suprasyndesmotic. According to Lauge-Hansen, 83 cases were supination-external rotation type (64.3%), and the remaining were pronation-external rotation type (35.7%) injuries. We found postoperative syndesmosis malreduction in 20 cases (15.5%). Eight (6.2%) cases had medial clear space mismatch. As the distance of the screw to the joint increased, postoperative medial clear space values increased (rho: 0.190, p = .031). The relationship between postoperative syndesmosis mismatch and the level of the syndesmotic screw was statistically significant (p = .044). In syndesmosis repair with a partially threaded screw, as the distance of the screw from the joint increases, the over-compression caused by the screw may cause an increase in postoperative syndesmotic malreduction rates.

Kinesiotaping therapy for midshaft clavicular fractures: a randomised trial study.

Midshaft clavicle fractures with shortening by less than 2 cm or minimal displacement without neurovascular injury can be treated conservatively. We hypothesized that kinesiotaping reduces the disadvantages of conservative treatment, such as early-phase pain, high nonunion rates, and a prolonged time to return to work, and yields better clinical and functional outcomes. Forty patients were randomly divided into the arm slings only (group S) or arm sling with kinesiotaping therapy group (group K). The outcome measures included the visual analog scale (VAS) score, Constant score, American Shoulder and Elbow Surgeons (ASES) score, union time, magnitude of shortening, and time to return to work. The mean follow-up period of the study was 8.5 (6- 10) months. The ASES and Constant scores were significantly better in group K than in group S in the 3rd month. The mean union time was 8.60 (8-12) weeks in group S and 8.25 (6-12) weeks in group K. The mean time to return to work was 7.23 (4-12) weeks in group S and 5.37 (2-10) weeks in group K, and the difference was statistically significant (p <0.05). There was no significant difference in terms of shortening between the two groups. Compared with an arm sling only, an arm sling with kinesiotaping can yield better clinical functional results, higher union rates, and a shorter the time to return to work due to the early control of pain and edema.

Retrospective analysis of 35 pediatric femoral neck fractures.

OBJECTIVE: Pediatric proximal femur fracture is extremely rare trauma comparing to other fractures. The proximal femur fracture is 1% of all pediatric fractures. The aim of current study is to compare the incidence of early complications and outcomes of pediatric proximal femur fractures regarding fracture types retrospectively. DESIGN: Our study includes 35 cases which are criticized by Delbet classification system, modalities of treatment, duration of waiting for surgery, duration of follow-up and also complications. Our inclusion criteria are age below 16 years old, proximal femur fractures with no evidence of tumoral, romathologic and methabolic conditions. Age, sex and surgery type (open-closed) were noted, and the data were statistically assessed. Assessment of the final outcome was made at the last follow-up visit using the Ratliff's method. RESULTS: The mean of age of patients in our study is 9.5 ± 5.06 years. The average follow-up was 25.6 ± 13.2 months. 15 patients (42.9%) are type 2 Delbet fracture, 5 patients (14.2%) are Delbet type 3 and 15 patients (42.9%) are Delbet type 4 fracture. Using the Ratliff's method, 25 patients (71.4%) had satisfactory outcomes. Ten patients (28.6%) had unsatisfactory outcomes. The complications as AVN, coxa vara and premature closure of physis, non-union and postoperative infections have been detected in this study. AVN was seen in four (11.4%) patients. In addition, coxa vara was seen in six (17.2%) patients. CONCLUSION: Pediatric femoral neck fractures are extremely rare fractures and can be treated with low complication rates in cases with early treatment and anatomic reduction.

Compatibility of Lauge-Hansen Classification Between Plain Radiographs and Magnetic Resonance Imaging in Ankle Fractures.

We evaluated the accuracy of the predictive injury sequences of the Lauge-Hansen (L-H) classification using magnetic resonance imaging (MRI) in patients with ankle fractures and determined the possible causes of mismatch. Sixty-five patients with ankle fractures who had a complete series of anteroposterior, lateral, and oblique radiographs and ankle MRI studies available were included. The fracture pattern was assigned by 2 senior orthopedic surgeons according to the L-H classification system. The syndesmotic ligaments, lateral collateral ligaments, and medial deltoid complex ligaments were evaluated on the preoperative MRI scans. Comparisons were performed between the predicted ankle ligamentous injury based on the radiographic L-H classification and preoperative MRI analysis. Of the 65 feet in 65 patients, 50 feet (76.9%) were classified as having a supination-external rotation (SER) fracture, 6 feet (9.2%) as having a pronation-external rotation fracture, 4 feet (6.2%) as having a supination adduction fracture, and 2 feet (3.1%) as having a pronation abduction fracture. The overall compatibility of the radiologic classification with the MRI classification was 66.1%. In the evaluation of 50 feet with the MRI SER designation, maximum compatibility was found for stage 4 (77.3%). The main cause for the discrepancy in the SER designation was missing the presence of deltoid ligament disruption on the plain radiographs, especially in the stage 2 and 3 SER fracture pattern. In the evaluation of deltoid complex injuries, all injuries were localized to the anterior part of the medial deltoid complex. The validity of the L-H classification system was low. A new classification system is needed to address the medial malleolus fracture or deltoid complex injuries without posterior injury. Also, stress radiographs could be added to standard radiographs for the classification to address deltoid complex injuries.

Quality of Life Following Treatment of Trochanteric Fractures with Proximal Femoral Nail versus Cementless Bipolar Hemiarthroplasty in Elderly.

PURPOSE: There is currently no gold standard treatment for unstable intertrochanteric fractures of the elderly. Internal fixation and hemiarthroplasty are two common treatment methods but studies comparing the functional outcomes of these procedures in the elderly are limited. This study evaluates the functional outcomes of hip fracture patients treated either with internal fixation or hemiarthroplasty. METHODS: Eighty-six elderly (>60 years) patients who presented with isolated, unstable intertrochanteric fractures between 2009 and 2013 were included in the study. According to the classification of Association for Osteosynthesis/Orthopaedic Trauma Association; 12 of the patients had a 31A1.3 fracture type, 36 of the patients had 31A2.2 and 19 had 31A2.3 fracture type, 12 had 31A3.1 and seven had 31A3.3 fracture. Forty-two of 86 hip patients (Group 1) were treated with intramedullary nailing and antirotator proximal femoral nail implant (TST, Turkey), and 44 (Group 2) were treated with cementless bipolar hemiarthroplasty. Preoperative social function (Jensen) score, EQ-5D index score and mobility (Palmer/Parker) scores were obtained. Five dimensions of EQ-5D were obtained at every follow-up visit until 24 months postoperative. RESULTS: There was no statistically significant difference between two groups according to preoperative demographic variables, including mean age and sex and Jensen, Palmer/Parker,EQ-5D index, five dimensions of EQ-5D and American Society of Anesthesiologists scores. At end of 24 months follow-up, health-related quality of life had increased more in Group 1 and they reported better social functioning and mobility scores (p<0.01). CONCLUSION: Internal fixation resulted in better social functioning and mobility scores compared with cementless bipolar hemiarthroplasty at the end of 24 months in treatment of unstable pertrochanteric hip fracture in the elderly.

Clinical results of cementless total hip arthroplasty with shortening osteotomy for high dislocation with developmental dysplasia.

Total hip arthroplasty for severe developmental dysplasia of the hip is a technically challenging procedure. Subtrochanteric femoral osteotomy enables reducing the femoral head and restoring abductor muscle strength without compromising proximal femoral bone stock in advanced dysplasia.We aimed to retrospectively evaluate Crowe type III or IV developmental dysplasia of the hip who underwent reconstruction with cementless total hip arthroplasty combined with a transverse subtrochanteric femoral osteotomy. Sixty hips of 52 patients (11 male, 49 female) with Crowe type III (n: 37) or IV (n: 23) developmental dysplasia of the hip were included. The average age was 51.4 years. Surgery was performed in lateral decubitis position with posterolateral approach. Subtrochanteric transverse femoral osteotomy were used with cementless components. 40 of the femoral components were Secur-Fit type, and 20 of them were secur-fit plus max type. Ceramic-ceramic coupling was used in 24 cases and metal-polyethylene coupling was used in 36 cases. Merle D'Aubigne and Harris Hip score were used to rate the clinical outcome at the final follow up. All femoral shortening osteotomies were united at a mean of 5.7 months. Mean Merle D'Aubigne pain score was increased from 3.1 to 5.4, and mean Harris Hip score improved from 39 to 92.8, postoperatively (p<0.01). There was no significant difference in time to union between different types of stems. 4 femoral stems had asymptomatic radiolucent lines. There was no significant difference in time to union between different types of stems.

The effect of inferomedial screw on postoperative shoulder function and mechanical alignment in proximal humerus fractures.

AIM: The aim of the study was to evaluate the clinical and radiologic results of locking plate fixation with or without inferomedial screw (IMS) in surgically treated proximal humerus fractures. PATIENTS AND METHODS: Thirty-six patients with displaced proximal humerus fractures from two centers were operated using locking plate. All of the fractures were classified according to the Neer classification. In 18 of the cases, an additional IMS running through the medial curvature of the surgical neck was used. There was no significant difference among both groups in terms of height, gender, weight, and mechanism of injury. The fractures were evaluated according to the radiographic and functional findings during follow-up period of 14 months in average (range 8-32 months). At the end of first year, shoulder radiographs were received and shoulder examinations were performed using ASES scores. Humeral head-shaft angles were measured by true AP projections. Head-shaft angle measurements were categorized as varus if <125, normal if between 125 and 145, and valgus if >145. RESULTS: Mean time for fracture healing was 18 weeks. Complete union was achieved in 35 patients by the end of 6 months. In one of the 18 displaced proximal humerus fractures of IMS (+) group, the head-shaft angle was measured to be <125, whereas six patients had varus deviation in IMS (-) group at follow-up (p < 0.05). Mean ASES scores of IMS (+) group and IMS (-) group were 58.21 ± 5.82 and 38.61 ± 3.44, respectively (p < 0.001). CONCLUSION: Use of inferomedial screw running through the medial curvature of surgical neck prevents varus deformity and improves functional outcome after surgical treatment for proximal humerus fractures.

Comparison of Functional Outcomes and Complications of Inlay and Onlay Reverse Shoulder Arthroplasty in Neer Type 4 Proximal Humerus Fractures and Cuff Tear Arthropathy: A Multicentric Study.

Background: This multicenter retrospective study was conducted with the objective of comparing the outcomes and complications between inlay and onlay reverse shoulder arthroplasty (RSA) in patients presenting Neer Type 4 proximal humerus fractures and cuff tear arthropathy. The primary aim of this investigation was to assess and juxtapose the clinical as well as functional outcomes of individuals who underwent onlay reverse shoulder arthroplasty with those who underwent inlay reverse shoulder arthroplasty. Methods: A retrospective cohort study was conducted, involving patients who had undergone reverse shoulder arthroplasty between the period of 2016 and 2022. The study divided the population into two groups: Group A received inlay humeral components, while Group B received onlay humeral components. Functional outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) and Constant scores. Range of motion, infection, periprosthetic fractures, and nerve injuries were also assessed. Results: The study included 67 patients in Group A and 62 patients in Group B. Group A had significantly better functional outcomes, as indicated by higher ASES and Constant scores (p < 0.05). Group A also had greater shoulder joint motion (p < 0.05). Periprosthetic fractures were significantly more common in Group B (p < 0.05). However, complication rates, including infection and instability, did not significantly differ between the groups (p > 0.05). Nerve injuries occurred in both groups, with slightly higher occurrence in Group B. Conclusion: Inlay humeral components in reverse shoulder arthroplasty for Neer Type 4 fractures and cuff tear arthropathy resulted in better functional outcomes, increased range of motion, and lower incidence of periprosthetic fractures compared to onlay components. Onlay components showed potential advantages in reducing instability rates. Further studies with larger samples and standardized protocols are needed to confirm these findings.

Arthroscopic Biological Augmentation With Subacromial Bursa for Bursal-Sided Partial-Thickness Rotator Cuff Tears.

Background: Augmentation with subacromial bursa has not been fully established in bursal-sided partial-thickness rotator cuff tears (PT-RCTs). Purpose: To compare the results of acromioplasty + arthroscopic debridement versus acromioplasty + augmentation with subacromial bursa for Ellman type 2 PT-RCTs involving 25% to 50% of the tendon surface area. Study Design: Cohort study; Level of evidence, 3. Methods: Included were 40 patients (mean age, 47.8 years) with Ellman type 2 PT-RCTs whose symptoms did not regress despite 3 months of nonoperative treatment. The patients underwent either acromioplasty + debridement (group A; n = 18) or acromioplasty + augmentation (group B; n = 22). Outcome scores (visual analog scale [VAS] pain score, Constant-Murley score [CMS], and American Shoulder and Elbow Surgeons [ASES] score) were obtained preoperatively and at 6, 12, and 18 months postoperatively. Magnetic resonance imaging (MRI) scans performed at 6 months postoperatively were used to determine the integrity and state of healing. Results: There were no significant differences between groups A and B in preoperative VAS, CMS, or ASES scores, and patients in both groups saw significant improvement at each follow-up time point on all 3 outcome scores (P = .001 for all). Scores on all 3 outcome measures were significantly better in group B than group A at each postoperative time point (P < .05 for all). Postoperative MRI scans revealed persistent partial tears in 5 of 18 patients in group A compared with 2 of 22 patients in group B (P < .05). Conversion to full-thickness tear (3/18 patients) was seen only in group A. Conclusion: Patients who underwent biological augmentation of their PT-RCTs had improved outcome scores compared with those treated with acromioplasty and debridement alone.

Distal Tibiofibular Malreduction in Ankle Fractures Received Fibula Plate and Syndesmotic Screw Fixation.

BACKGROUND: The aim of the study was to examine the effect of the position of the plate and syndesmotic screw on postoperative tibiofibular joint malreductions in cases where the syndesmotic screw is inserted through the hole of the anatomically locked lateral distal fibula plate. METHODS: Thirty patients (13 female and 17 male patients) with postoperative computed tomographic scans were examined retrospectively. Patient information (eg, tibiofibular congruence measured from postoperative computed tomographic scans, the anterior and posterior tibiofibular distance at axial sections, the presence and orientation of fibular rotation, the presence of tibiofibular intraarticular piece, the angle between the syndesmotic screw and incisural line, the placement of the plate, and the localization of the screw on the fibula in axial images) was recorded. RESULTS: Those with fibular internal rotation had a lower syndesmotic screw-incisural line angle (SIA) (P = .001).There was a very strong negative significant correlation between the tibiofibular angle and SIA (rho, -0.780; P = .001). The median tibiofibular angle was found to be higher in cases with the fibula plate placed anteriorly (P = .009).The median SIA was found to be lower in cases with the fibula plate placed anteriorly (P = .004).The rate of placement of syndesmotic screw in the anterior third of the fibula was found to be high in cases with the fibula plate placed anteriorly (P = .049). CONCLUSIONS: In ankle fractures treated with insertion of a syndesmotic screw through the plate, the orientation of the syndesmotic screw in the axial plane and the position of the plate may be associated with the incidence of postoperative syndesmosis malreduction.

Feasibility of diagnosing osteoporosis using routine computed tomography scans for hip fractures: Correlation with histopathological diagnosis of head and neck regions.

OBJECTIVE: The aim of this study was to demonstrate the feasibility of diagnosing osteoporosis through routine computed tomography (CT) by assessing the association between the histopathological assessment of femoral head specimens extracted from patients who underwent surgery for intertrochanteric fractures and the Hounsfield unit (HU) measurements derived from preoperative CT scans. METHODS: Forty-eight patients who presented to our clinic between November 2019 and May 2020 with hip fractures and underwent partial prosthesis fixation were included in this retrospective study. Hounsfield unit measurements were performed on the head and neck regions using dual-energy x-ray absorptiometry (DEXA) and CT scans, respectively. The trabecular ratio per unit area was calculated using the Nikon Imaging Software (NIS-Elements ) program in the pathology laboratory from digitally captured images of the removed head and neck specimens. RESULTS: The mean HU receiver operating characteristic analysis had a sensitivity of 77% and a specificity of 87%, with a cutoff value of 77.68. There was a moderate correlation between the mean trabecular density and the mean HU of the femoral head (P=0.013, r=0.340). Additionally, there was a significant correlation between the mean HU and the T-score of the head, although this correlation was not found with the maximum-minimum HU. Although there was a significant correlation between trabecular density and mean HU, the correlation coefficient indicated a moderate relationship. This relationship was also observed between the inferior sections of the head and the trabecular density and HU (P=.018). However, no significant correlation was found between the T-score and the trabecular structure of the head (P=.977). CONCLUSION: The results of the present study suggest that conventional CT has the potential to serve as a diagnostic tool for osteoporosis and may offer a more precise and accurate method for evaluating the success of intraosseous implants when compared to T-scores without the need for additional tests or procedures.

Effect of psoas and gluteus medius muscles attenuation on hip fracture type.

INTRODUCTION: Sarcopenia is defined as a progressive loss of muscle mass and function with increased age. The measurement of muscle mass and attenuation on the axial computed tomography (CT) scan has been reported to be a good indicator for sarcopenia in previous literature. This study aimed to compare muscle mass between the intertrochanteric fracture and femoral neck fracture groups by accurately measuring muscle mass around the hip joint using a CT scan. METHODS: The cases were matched according to age and gender on a 1-to-1 basis. As a result, a total of 400 patients, 200 patients in each group with the same age and gender characteristics, were included in the study. At the disc of L4-L5 level, the cross-sectional area (CSA) of the psoas muscle was evaluated, and at the disc of L5-S1 level, the CSA of the psoas, iliacus and gluteus medius muscles were evaluated. In addition, attenuation was evaluated using the average Hounsfield Unit (HU) for the specific area. RESULTS: The mean age of 400 patients (262 females, 138 male) included in the study was 78.49 ± 7.67 years. It was observed that the mean HU values of the patients in the femoral neck fracture group were significantly higher than the intertrochanteric fracture group (p < 0.001, p = 0.008; respectively). At the same time, the mean HU values of the gluteus medius muscle were higher in the femoral neck fracture group (p < 0.001), but in contrast with the psoas muscle, the CSA values of gluteus medius muscle were significantly higher in the intertrochanteric fracture group (p = 0.017). CONCLUSIONS: Fatty degeneration of the psoas muscle among the muscles around the hip may affect the type of hip fracture. Elderly patients with strong psoas muscles may experience femoral neck fracture due to contraction and torsion during falling.

Comparison of Supination-Adduction Type 2 and Supination-External Rotation Type 4 in Bimalleolar Ankle Fractures: Does Partial Pylon Variant of Supination-Adduction Type Fracture Affect Functional Outcomes?

BACKGROUND: Supination-adduction (SAD) type injuries are pylon variant injuries and lie between partial intra-articular pylon fractures and rotational ankle fractures. We aimed to evaluate functional outcomes of SAD type 2 bimalleolar fractures in comparison to supination-external rotation (SER) type 4 fractures. METHODS: We retrospectively reviewed data of 42 cases with SER type 4 and 20 cases with SAD type 2 injuries. Patients with a history of rheumatic disease, open fractures, pathologic fractures, nonbimalleolar fractures, neuropathic disease, and talus osteochondral lesion, and those operated on after greater than 72 hours because of skin lesion or managed with a two-stage surgical protocol after external fixation, were not included in the study. We compared these two groups in terms of the mean age, follow-up time, visual analog scale pain and American Orthopedic Foot and Ankle Society scores, Kellgren-Lawrence arthrosis classification, union time, and complications. RESULTS: The groups did not differ in terms of mean age (P = .115) and sex (P = .573). There was no significant difference in terms of union time between the groups (P = .686). American Orthopedic Foot and Ankle Society score was significantly higher in the SER group (91.2 ± 9.9) than in the SAD group (86.1 ± 13.2; P = .034). Visual analog scale pain scores were similar in the SAD (0.3 ± 0.92) and the SER (0.26 ± 0.7) groups (P = .897). CONCLUSIONS: Supination-adduction bimalleolar fractures may have worse functional outcomes in the intermediate term than do SER bimalleolar fractures, implying pylon variant fractures as a mechanism of injury. Supination-adduction bimalleolar fractures might be associated with a high rate of intra-articular cartilage impaction, resulting in varus deformity after surgery.

Syndesmosis Injuries in Lateral Malleolar Fractures Accompanied by a Posterior Malleolar Fracture: A Nonfixed Posterior Fracture Fragment May Not Affect Postoperative Tibiofibular Joint Malreduction Rates.

BACKGROUND: The fact that lateral malleolar fracture is accompanied by posterior malleolar fracture may adversely affect syndesmosis malreduction rates. We aimed to compare syndesmosis malreduction rates determined on postoperative radiographs between isolated lateral malleolar fractures and lateral malleolar fractures accompanied by posterior malleolar fractures. METHODS: We retrospectively examined 128 operative patients: 73 with isolated lateral malleolar fractures (group L) and 55 with lateral + posterior malleolar fractures (group LP). In group LP, no patients received posterior fragment fixation. In both groups, indirect syndesmosis fixation was performed with a single screw after open reduction and internal fixation of the lateral malleolus. Patient age, sex, fracture side, fracture type (Lauge-Hansen and Danis-Weber classifications), Kellgren-Lawrence osteoarthritis classification, syndesmotic incongruency on postoperative radiographs, syndesmotic malreduction of postoperative fibula fracture, fracture union time, complication rates, accompanying injuries, and preoperative and postoperative radiographic syndesmotic measurements (tibiofibular overlap, tibiofibular clear space, medial clear space) were recorded, and the groups were compared. RESULTS: Mean ± SD age was 44.32 ± 15.66 years in group L and 48.93 ± 14.03 years in group LP (P = .087). There were no significant differences in preoperative and postoperative tibiofibular distance, tibiofibular overlap, and medial clear space values between groups (P > .05). The prevalence of grade 2 fractures according to the Kellgren-Lawrence classification was significantly higher in group LP (P = .047). Postoperative syndesmosis malreduction was detected in 12 patients in group L and in nine in group LP (P = .991). CONCLUSIONS: In lateral malleolar fractures accompanied by small-fragment posterolateral or avulsion-type posterior malleolar fractures, closed syndesmotic screw fixation does not cause syndesmosis malreduction.

Does Sectioning and Then Repairing of the Calcaneofibular Ligament at Subtalar Approach Lead to Residual Lateral Ankle Instability?

Background: The calcaneofibular ligament is cut to increase vision in surgical field in minimally invasive surgery of displaced intraarticular calcaneus fractures with subtalar incision. We aimed to investigate whether this causes talar tilt instability in ankle stress radiographs due to the calcaneofibular ligament deficiency in postoperative period. Methods: The files of 38 patients who were operated with the diagnosis of displaced calcaneus fracture between 2013 and 2018 were examined retrospectively. All the cases underwent with subtalar approach and the calcaneofibular ligament was repaired after the operation. The age, sex, injury mechanism, follow-up length, type of fracture by the Sanders classification, preoperative and postoperative Bohler's and Gissane's angle measurements, talar tilt measurements of intact and fractured side, postoperative calcaneal length, calcaneal height and calcaneal width of the cases were recorded. The obtained data were evaluated statistically. Results: 31 (81.6%) of the cases were men, seven (18.4%) were women. The average age was 31.92±7.95 years. The average follow-up time was 15.82±3.33 months. The preoperative Bohler's angle was 14.16±3.67 degree, while the postoperative Bohler's angle was 31.53±4.60 degree (P<0.05). The average talar tilt was 0.96±0.87 degrees on the intact side and 1.19±1.12 degrees on the fractured side (P:0.001). Although the talar tilt values were statistically higher on the fractured side than the intact side, no radiological instability finding was found in any case. The average postoperative Gissane's angles were 126.45±6.69 degrees. The calcaneal length (P:0.665), calcaneal width (P:0.212) and calcaneal height (P:0.341) were statistically similar between the postoperative fractured foot and intact foot. Conclusion: Sectioning of the calcaneofibular ligament in the surgical treatment with subtalar approach does not cause lateral ankle instability in stress radiographs but may cause laxity. Possible postoperative lateral ankle injuries can be prevented by ankle proprioception exercises.

Shoulder Proprioception Following Reverse Total Shoulder Arthroplasty for Unreconstructable Upper Third Fractures of the Humerus: 2-Year Outcomes.

Background: Proximal humerus fractures may be comminuted in the elderly or after injury with high-energy mechanisms. Reverse total shoulder arthroplasty that may affect shoulder proprioception (rTSA) has also begun to play a part in treating acute proximal humeral fractures. In this study, the authors aimed to evaluate joint position sense (JPS) after rTSA. Methods: Humac Norm II isokinetic device was used to evaluate the joint position sense. A joint angle was determined and the ability of the patient to create the same value of the angle by the active movement was evaluated. The difference between the pre-determined angle and the patient's measured angle was recorded. For proprioceptive sense, the initial position was 0° and the determination position was 30°, 60°, and 90° for flexion and abduction, and 15° and 30° for internal rotation and external rotation. Results: While both the mean Constant and ADLEIR scores did not differ between non-operated and operated sides, the mean proprioception differences in all flexion (30°, 60°, and 90°), abduction (30°, 60°, and 90°), internal rotation (15° and 30°), and external rotation (15° and 30°) were significantly higher in the operated side than that in non-operated side (p < 0.01 for each pairwise comparison). Conclusion: Reverse total shoulder arthroplasty (rTSA) treatment, which has increasingly become a surgical option in un-reconstructable proximal humeral fractures has significant adverse effects on proprioception on the operated side and may pose a risk for long-term instability, premature loosening, and prosthesis mechanical complications, in this context, well-designed prospective controlled studies are required.

The effect of gluteus maximus tenotomy in primary total hip arthroplasty with posterior approach: Kinematic analysis of hip extensor strength.

BACKGROUND: The posterior approach (PA) is the most commonly used surgical approach for total hip arthroplasty (THA), but the proximity of the sciatic nerve may increase the likelihood of sciatic nerve injury (SNI). Gluteus maximus tenotomy can be performed to prevent SNI because tenotomy increases the distance between the femoral neck and sciatic nerve and prevents compression of the sciatic nerve by the gluteus maximus tendon (GMT) during hip movements. We aimed to kinematically compare the postoperative hip extensor forces of patients who have and have not undergone gluteus maximus tenotomy to determine whether there is a difference in hip extensor strength. METHODS: Seventy-two patients who underwent gluteus maximus tenotomy during THA were included in the group 1, and 86 patients who did not undergo tenotomy were included in group 2. The Harris hip score, body mass index and hip extensor forces were measured both preoperatively, and 6 months after surgery with an isokinetic dynamometer and compared. RESULTS: The mean age was 64.6 ± 2.3 years in group 1 and 63.8 ± 2.1 in group 2. Mean body mass index was 25.7 ± 1.1 in group 1, and 25.5 ± 1.3 in group 2. Baseline Harris hip score (HHS) was 42.36 ± 12 in group 1 and 44.07 ± 9.4 in group 2 (p = 0.31), whereas it was 89.1 ± 7.8 and 88.4 ± 8.1 at 6 months after surgery, respectively. Baseline hip extensor force (HEF) was 2 ± 0.4 Nm/kg in group 1, and 2.1 ± 0.7 Nm/kg in group 2 (p = 0.28), while it was 2.4 ± 0.6 Nm/kg, and 2.5 ± 0.5 Nm/kg, respectively at 6 month follow-up (p = 0.87). Both groups had significantly improved HHS and HEF when comparing baseline and postoperative measurements (p < 0.0001). No cases of sciatic nerve palsy were noted in group 1, whereas there were two (2.32%) cases in group 2, postoperatively. CONCLUSION: The release of the GMT during primary hip arthroplasty performed with the PA did not lead to significant decrease in hip extension forces. Hip extensor strength improves after THA regardless of tenotomy. Gluteus maximus tenotomy with repair does not reduce muscle strength and may offer better visualization.