Peroneal artery injury potential due to different syndesmosis screw placement options: a simulation study with lower extremity computed tomography angiography.

INTRODUCTION: The aim of this study is to assess the risk of peroneal artery injury of hardware placement at the fixation of syndesmotic injuries. MATERIALS AND METHODS: The lower extremity computed tomography angiography was used to design the study. The syndesmosis screw placement range was simulated every 0.5 cm, from 0.5 to 5 cm proximal to the ankle joint. The screw axes were drawn as 20°, 30° or individual angle according to the femoral epicondylar axis. The proximity between the screw axis and the peroneal artery was measured in millimeters. Potential peroneal artery injury was noted if the distance between the peroneal artery to the axis of the simulated screw was within the outer shaft radius of the simulated screw. The Pearson chi-square test was used and a p-value < 0.05 was considered significant. RESULTS: The potential for injury to the peroneal artery increased as the syndesmosis screw level rose proximally from the ankle joint level or as the diameter of the syndesmosis screw increasds. In terms of syndesmosis screw trajection, the lowest risk of injury was observed with the syndesmosis screw angle of 20°. Simulations with a screw diameter of 3.5 mm exhibited the least potential for peroneal artery injury. CONCLUSION: Thanks to this radiological anatomy simulation study, we believe that we have increased the awareness of the peroneal artery potential in syndesmosis screw application. Each syndesmosis screw placement option may have different potential for injury to the peroneal artery. To decrease the peroneal artery injury potential, we recommend the followings. If individual syndesmosis screw angle trajection can be measured, place the screw 1.5 cm proximal to the ankle joint using a 3.5 mm screw shaft. If not, fix it with 30° trajection regardless of the screw diameter at the same level. If the most important issue is the peroneal artery circulation, use the screw level up to 1 cm proximal to the ankle joint regardless of the screw angle trajection and screw diameter.

Dimple of Venus Is Associated with the Increased Pelvic Incidence Angle and More Sagittally Oriented Facet Joint.

OBJECTIVES: The present study aims to investigate whether the dimple of Venus affects the anatomy of spinopelvic junction. SUBJECTS AND METHODS: Inclusion criteria were having a lumbar MRI examination in the last 1 year, being older than 18 years of age and being able to radiologically evaluate the whole vertebral colon and pelvic girdle. Exclusion criteria were having congenital diseases of the pelvic girdle/hip/vertebral column and history of fracture or previous surgery in the same anatomic regions. The patients' demographic data and low back pain were noted. At radiological examination, the pelvic incidence angle was measured by lateral lumbar X-ray. The facet joint angle, tropism, facet joint degeneration, intervertebral disc degeneration, and intervertebral disc herniation at the level of L5-S1 were examined on lumbar MRIs. RESULTS: We included 134 male and 236 female patients with a mean age of 47.86 ± 14.50 years and 48.49 ± 13.49 years, respectively. We found that the patients with the dimple of Venus had higher pelvic incidence angle (p < 0.001) and more sagittally oriented facet joint (right facet joint p = 0.017, left facet joint p = 0.001) compared to those without the dimple of Venus. There was no statistically significant relationship between low back pain and the presence of the dimple of Venus. CONCLUSIONS: The dimple of Venus affects the anatomy of the spinopelvic junction and is associated with an increased pelvic incidence angle and a more sagittally oriented facet joint angle.

The histopathological effects of sleep disorders on striated muscle in rats.

OBJECTIVES: To histopathologically examine the change in gastrocnemius muscle created by sleep disorder in rats. METHODS: This study was carried out at Giresun University, Turkey from December 2018 to January 2021. A total of 30 Wistar rats were separated into 3 groups as the control group (CG), absence of rapid eye movement (REM) sleep (ARS) group, chronic absence of sleep (CAS) group. The lack of sleep was created in all rats. At the end of 21 days, all the rats were euthanized. Degeneration and regeneration findings, and expressions of muscle RING finger 1 (MuRF1), muscle atrophy F-box (MAFbx), tumor necrosis factor (TNF), cyclooxygenase 2 (COX 2), insulin-like growth factor 1 (IGF1) in the gastrocnemius muscles were evaluated histopathologically and immunohistochemically. RESULTS: Degeneration was found to be greater in the ARS and CAS groups compared to the CG. Regeneration was determined to be significantly lower in the CAS group compared to the ARS group and control group. The number of atrophic fibres was greater in the CAS and ARS groups than in the control group. The IGF1 staining in the CAS group was found to be stronger than in the other 2 groups. CONCLUSION: This study demonstrated an increase in findings of degeneration in the gastrocnemius muscle of rats with a lack of sleep. The regeneration was reduced in the group with chronic lack of sleep.

The prevalence of fabella and its relationship with the lateral posterior condylar offset and lateral posterior tibial slope values.

OBJECTIVES: This study aims to analyze whether the lateral posterior condylar offset (LPCO) and lateral posterior tibial slope (LPTS) values are associated with the presence of fabella by evaluating the frequency of fabella, its location, and whether it is bilateral and the relationship of the fabella with age, sex, and the presence of osteoarthritis. PATIENTS AND METHODS: Between January 2016 and December 2020, computed tomography (CT) scans including 1,952 knee regions of 1,220 patients (861 males, 359 females; mean age: 54.5±19.7 years; range, 10 to 98 years) were retrospectively analyzed. Age, sex, and the presence of fabella whether unilateral (left or right) or bilateral were recorded. Of the patients with a bilateral knee CT, those with fabella on one side and without on the other were studied further to investigate the effect of fabella on the posterolateral corner (PLC). In these patients, the LPCO and LPTS values, presence of knee osteoarthritis, fabella-femoral distance, and sagittal anterior-posterior diameter of the fabella were evaluated. RESULTS: While there was no evidence of fabella in 867 (71.1%) patients, it was present in 353 (28.9%) patients. The linear correlation analysis revealed that the correlations between the right LPCO and the right LPTS (r=-0.295; p<0.001) and between the left LPCO and the left LPTS (r=-0.574; p<0.001) were significant. It was observed that LPTS decreased with increasing LPCO. According to the results of the point biserial correlation analysis, there was a significant correlation between the presence of fabella on the right side and the right LPCO value (r=-0.643; p<0.001) and between the presence of fabella on the left side and the left LPCO (r=-0.284; p=0.024). When the two knees were compared, fabella was less present in the knee whose LPCO was higher than that of the other knee, whereas it was more common in the knee whose LPCO was lower than that of the other knee. We found a significant correlation between each side's fabella and LPCO values and between the presence of fabella on the left side and the left LPTS. CONCLUSION: The presence of fabella in the knee joint may be associated with LPCO and LPTS values of the knee. The comparison of the two knees of the same patient may reveal that if a fabella is present in a knee, the LPCO value of that knee is lower than that of the other knee. We believe that the reason for this is that the presence of fabella increases the distance to the center of rotation of the knee joint.

Reliability of Fossae Lumbales Laterales and Pelvic Incidence for Estimating Transsacral Corridors Assessed Using Reconstruction Computed Tomography.

Background: The present study aimed to evaluate the effect of fossae lumbales laterales and pelvic incidence (PI) on transsacral corridors. Methods: Patients who underwent pelvic computed tomography (CT) during routine therapy in a single center between 2015 and 2020 were retrospectively reviewed. The patients' age and sex were documented during CT examination. Measurements were performed for both the upper and second sacral segments. Height and weight of the patients were determined using appropriate tools and body mass index (BMI) was calculated. Transsacral corridors were identified in true coronal and true sagittal planes and their width was determined as the maximum gap measured so that no screws could come out of the transacral corridors. PI was measured. Results: Our study included 244 (57%) male and 184 (43%) female patients, who had a mean age of 49.3 ± 14.15 years (range, 18-89 years) and a mean BMI of 26.57 ± 2.38 kg/m2. No statistically significant correlation was found between the detection of the dimple sign in physical examination and the presence of an adequate corridor. The PI was statistically significantly higher in the patients with dimples (p < 0.001). PI of the female patients was higher than that of the male patients (p = 0.026). The correlation between PI and the existence of adequate corridors for S1 and S2 screws was not statistically significant (p = 0.858 and p = 0.129, respectively). On the relationship between the presence of adequate S1 and S2 corridors where transsacral screws could be sent, an inverse relationship was detected: if the S1 transsacral corridor was adequate, the S2 corridor was inadequate or vice versa. Conclusions: We could not obtain meaningful results on the use of the dimples of Venus or PI instead of CT to evaluate the adequacy of transverse corridors. Nevertheless, we confirmed that an increased PI was associated with the presence of dimples of Venus.

Mean Platelet Volume to Platelet Count Ratio as a Predictor of Mortality in Unstable Pertrochanteric Fracture Treated with Short Proximal Femoral Anterograde Nail.

Introduction: The relationship between mean platelet volume (MPV) and platelet count (PC, MPV/PC) has been studied in detail in various diseases. The aim of this study was to investigate the effect of the MPV/PC ratio in estimating the risk of postoperative mortality in unstable pertrochanteric fractures. In addition, serum biomarkers such as the neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and platelet-to-lymphocyte ratio (PLR) will be compared with the MPV/PC ratio in predicting mortality. Materials and Methods: We retrospectively reviewed the records of eligible adult patients with a pertrochanteric fracture who admitted to the Department of Orthopedics and Traumatology between January 2011 and December 2019. The MPV/PC ratio was estimated as the MPV value divided by the PC at admission, postoperative day 2, and postoperative day 5 of the surgery. The clinical outcome was 30-day mortality and overall mortality. Results: We included 447 patients who received unstable pertrochanteric fracture surgery. In multivariate Cox proportional hazard models, higher MPV/PC ratios on admission were significant risk factors for 30-day mortality. In the ROC analysis, MPV/platelet ratio ≥ 0.048 at admission was critical for 30-day mortality (sensitivity 0.636, specificity 0.659, p < 0.001). Discussion: The MPV/PC ratio alone predicted 30-day mortality in patients with pertrochanteric fracture. Further prospective and multicenter clinical trials supporting our findings and aiming to uncover the reason for the change in blood parameters will help to reduce mortality in unstable pertrochanteric fractures.

Necrotizing Fasciitis After Total Hip Arthroplasty: A Rare Case Presentation.

BACKGROUND: Necrotizing fasciitis (NF) is a life-threatening disease. Arthroplasty patients with underlying or preexisting conditions and chronic medication use are prone to infection. The current report aimed to present a 53 years old female patient who developed necrotizing fasciitis one month after total hip arthroplasty. CASE PRESENTATION: On the postoperative 15th day, she had wound discharge. She was given oral anti- biotherapy. At postoperative 1 month, her complaints increased. At emergency service, she experienced extreme pain in her lower extremity with pseudoparalysis, and a hip X-ray revealed gas images. She used prednisolone for 10 years and insulin for 15 years because of pemphigus vulgaris and diabetes mellitus. Clinical and laboratory findings led us to the diagnosis of necrotizing fasciitis. Despite aggressive treatment, including debridement, prosthesis removal, and antibiotherapy, unfortunately, the patient died 13 days after admission. CONCLUSION: Patients with an immune suppressive condition, long-term corticosteroid use, or multiple underlying diseases should be closely monitored after total hip arthroplasty surgery to avoid such a devastating complication.

Evaluation of Necrotic, Edematous and Inflammatory Changes in Bone Marrow and Soft Tissue After Irrigation with Different Concentrations of NaOCl Solution: An Experimental Study in Rat Tibia.

OBJECTIVE: We aimed to investigate effects of different concentrations (0.5-5%) of Sodium Hypochlorite (NaOCl) solution on healthy tissues, and determine the optimal concentration that does not harm to tissue. MATERIALS AND METHODS: 30 tibias of 15 male Wistar albino rats were used. The tibias were randomly divided into 5 groups (Salin, 0.5%, 1%, 2.5%, and 5% NaOCl). Tibias were reamed intramedullary, and irrigated with 20 ml of saline or increasing concentrations of (0.5-5%) NaOCl. The tibias were embedded in paraffin and the sections were stained with hematoxylin-eosin. All sections were assessed for edema, acute inflammation, or necrosis according to their density, in bone marrow and soft tissues. RESULTS: Pairwise comparisons revealed that irrigation of tibia with saline or 0.5% NaOCl solutions was not statistically significant in terms of necrosis in the bone marrows (p=0.320). However, irrigation of rat tibia with saline caused less necrosis in the bone marrows compared to high concentrations (1%, 2.5%, and 5%) of NaOCl (saline and 1% NaOCl, p=0.017; saline and 2.5% NaOCl, p=0.0007; saline and 5% NaOCl, p=0.001). CONCLUSION: As an irrigation solution, the effects of 0.5% NaOCl are similar to those of saline in terms of edema, inflammation, and necrosis. There is a need for evaluation of necrosis for extended periods such as one week or one month by immunohistochemical methods and flow cytometry.

Evaluation of different intraarticular injection volumes to assess optimum efficient amount; an experimental study in rat knee joints.

INTRODUCTION: The injection amount of solutions differs in wide ranges, from 20 to 200 µL in intraarticular injections experiments that was carried out with rats. The 10-fold difference between applied volumes is not acceptable since injection errors might affect the outcomes of the studies significantly. The excessive amount of solution that was injected into the knee joint of rats might end up with leakage of the solution from injection aperture, and damage the articular structures etc. In our preliminary experiments, we mentioned problems during the injection of excessive amount of solution into the rat knee joint. The main purpose of the present study, which was performed with rat knee joints, was to evaluate the applicability of different amounts of solutions used in experiments and to determine the optimal volume for intraarticular injection in rats. METHODS: The volume of 100 µL water-based stain was administered into knee joints of non-living rats. The legs were dissected to evaluate the possible presence of injected solution outside the knee joint. Then, the decreasing volumes (100 µL, 50 µL, 40 µL and 30 µL) of X-ray contrast solution (lobitridol) were applied into the knees of living rats to investigate whether systemic circulation acts on the leakage outside the joint. The X-ray images of all these joints were also taken to confirm the results. RESULTS: In nonliving rats, the place where water-based strain overflow from the knee joint was pointed out. The place of leakage is where the tendo musculi extensor digitorum longus leaves outside the joint. In living rats, by using contrast solution, an overflow was noticed in the subdermal place with the intraarticular injection volumes of 100 µL, 50 µL, and 40 µL. No overflow was observed with the intraarticular injection volumes of 30 µL X-ray contrast solution. DISCUSSION: In conclusion, the injection volume for the knee joints of rats should not exceed the 30 µL for optimum efficiency.

Assessment rate of true dorsogluteal intramuscular drug injection using ultrasonography.

OBJECTIVE: Medications are generally administered by either the enteric or parenteral route. With parenteral administration, intramuscular (IM) is the preferred approach because it increases the bioavailability of the drug, acts more quickly than the enteric route. The aim of this study was to determine the rate of true dorsogluteal intramuscular drug injection and to determine the causes for application failures in practice by ultrasonography (US). METHODS: The study was conducted from May 1 to May 30, 2017 in Giresun University Education and Research Hospital, Giresun, Turkey. We examined 60 patients who were administered dorsogluteal IM injection with a 38.1mm length needle. After the injection, localization of medications (whether intramuscular or subcutaneous adipose tissue [SAT]) was evaluated by Ultrasound. RESULTS: Female/male ratio of the patients was 27/33, with a mean age of 39.78±2.16 years. Obese/normal weight ratio was 20/40. The mean dorsogluteal area SAT thickness of obese and normal weight patients were 32.34±2.17 mm and 20.85±1.20 mm, respectively. In 23 of the patients, IM injected drug was observed in the SAT, while it was observed in the IM area in 37 patients. Medication was observed in IM area in 37 of 50 patients who dorsogluteal region SAT thickness was appropriate (SAT thickness lower than 33.1mm) for IM injection while it was seen in SAT area in 13 patients. CONCLUSIONS: SAT thickness values are important if IM drug injection is to be administered correctly. Unsuccessful IM injections may be seen even in patients with appropriate SAT thicknesses.

Minimally Invasive Surgical Approach Using an Equal-Sized Plate as an External Guide to Lateral Malleolar Fractures.

BACKGROUND: For minimally invasive percutaneous plate osteosynthesis (MIPPO) techniques applied to fractures of the lateral malleolus, there is no external guide for inserting the plate, determining the incision, and inserting the screws as used for fractures in other regions. With MIPPO, fluoroscopy exposure is unavoidable. The MIPPO technique is advantageous for patients; however, the unavoidable problem with this method for the surgical team is repeated exposure to fluoroscopy. To expose the surgical team to least radiation, we used a novel technique with an equal-sized plate as an external guide. We present the results of patients treated with this technique. METHODS: Patients with isolated lateral malleolar fracture who underwent MIPPO using an equal-sized anatomical lateral malleolar plate as an external guide were retrospectively investigated. VAS scores on postoperative day 1 and AOFAS scores at final evaluation were noted. RESULTS: Twenty-six patients were included in the study. Mean ± SD follow-up was 42.46 ± 14.11 months. Mean ± SD VAS score on postoperative day 1 was 3.76 ± 2.58. On final evaluation, prominent implant was identified in two patients, with mean ± SD AOFAS score of 98.00 ± 2.17. No other complications were observed. CONCLUSIONS: Using an equal-sized plate as external guide may ensure less use of fluoroscopy while determining the incisions. Until an external guide is produced commercially for minimally invasive fixation of lateral malleolar fractures, this method ensures determination of incisions and insertion of screws without requiring the use of fluoroscopy and may be reliably used for minimally invasive surgery.

Intra-articular injection of hydrogen sulfide decreased the progression of gonarthrosis.

Hydrogen sulfide (H2S) is found in both the plasma and synovial fluid of patients with gonarthrosis. In the present study, we investigated whether intra-articular injection of sodium hydrosulfide (NaSH) (1 mM, 30 µL), a H2S donor, might affect gonarthrosis in rats. Gonarthrosis was induced surgically in the left knees of rats and left for 6 weeks for the development of disease. Then, intra-articular injections of NaSH or methylprednisolone (1 mg/kg, 30 µL) were administered to rats. Half of each group was sacrificed at the end of the first day and the other half was sacrificed at the end of 4 weeks to evaluate early and later effects of injections on gonarthrosis. The injury induced by anterior cruciate ligament resection and medial meniscectomy in rats caused the development of gonarthrosis. As the duration lengthened after gonarthrosis induction, the progression of the disease continued. According to the modified Mankin Scoring System, intra-articular injection of NaSH histopathologically slowed the progression of gonarthrosis, whereas methylprednisolone was ineffective. In addition, NaSH decreased apoptosis in rat knees with gonarthrosis. Each treatment did not cause injury to healthy knees. Our results lead to the consideration that intra-articular NaSH administration may be effective in the progression of gonarthrosis.

Caecum location in laboratory rats and mice: an anatomical and radiological study.

Intraperitoneal (i.p.) injection is the most frequently used method for implementing parenteral therapies in rats and mice. Whether the caecum is located in the right caudal quadrant or left caudal quadrant in the abdominal cavity is not clear. For that reason, we have developed a method for identifying the location of the caecum in rats and mice and thus revealed the most reliable location for i.p. injection in these animals. Two hundred Wistar albino rats and 100 BALB/c mice were used. The location of the caecum was determined by revealing the intra-abdominal organs immediately following euthanasia, photographing the organs, and archiving the images. Both digital photographic images and computed tomographic (CT) sections were analysed in terms of caecum morphology and location. In both rats and mice, the caecum was most commonly located on the animal's left side. It was less frequently located on the right side or in the centre. The caecum was typically comma-shaped, but it was round or S-shaped in some animals. The direction of rotation of the caecum from the basis to the apex was mostly counterclockwise. Additionally, the apex showed a tendency to be evenly centred. This study demonstrated that the caecum was mostly located on the animal's left side; and for that reason, the most suitable location for i.p. injection in these animals was understood to be the right caudal quadrant. Furthermore, when we compared the CT images and autopsy findings, the caecum did not change location in the abdominal cavity postmortem.

Autologous Blood Injection Works for Recalcitrant Lateral Epicondylitis.

BACKGROUND: Recalcitrant lateral epicondylitis may be a disabling condition. Treatment of this condition is still controversial. AIMS: In the present prospective study, we evaluated the long-term results of autologous blood injection for the treatment of recalcitrant lateral epicondylitis. STUDY DESIGN: Prospective clinical study. METHODS: A total of 42 elbows of 40 consecutive patients (28 female, 12 male) were enrolled in this prospective study. Seven patients left the study (3 patients moved to another city, 1 patient died in the second week due to a heart condition, 1 patient quit the study because of the resolution of pain in the fourth week and 2 patients did not agree to the second injection). Thirteen patients were lost to third year follow-up. Therefore, a total of 21 elbows of 20 patients with 3 years of follow-up were included in this study. The mean age of the patients was 47.25 years (range, 20-68 years). RESULTS: Visual analogue scale (VAS), Nirschl score and grip strength were significantly improved after injections when compared to before treatment. The best improvement in terms of grip strength, Nirschl score and VAS score was detected at the one year follow-up. The improvement in Nirschl and VAS score sustained until the third year. CONCLUSION: We suggest that autologous blood injection for the treatment of recalcitrant lateral epicondylitis is an effective, safe and successful procedure in the long-term.