How successful is synthetic graft treatment for children with pathological hip fractures?

PURPOSE: To determine whether synthetic grafts are a satisfactory treatment option for pathological proximal femoral fractures in children. METHODS: Paediatric patients treated for pathological fractures of the proximal femur between 2013 and 2020 were evaluated retrospectively. 17 patients with a mean age of 10.7 years (range 6-16 years) were assessed. The definitive histopathological diagnoses were SBC (simple bone cyst) (12) and ABC (aneurysmal bone cyst) (5). The median duration of follow-up was 37 months (range 12-70 months). RESULTS: All patients returned to their normal daily routine within 3-8 months following surgery. The mean post-op recovery time was 3.2 months (range 3-6 months). Graft was incorporated at approximately 12 months. No significant radiographic healing was observed in 2 patients. In the remaining 15 patients, the mean duration of healing was 14 months (range 8-24 months). CONCLUSION: Synthetic grafts are a satisfactory treatment option for pathological proximal femoral fractures in children.

Anatomic footprint of the direct head of the rectus femoris origin: cadaveric study and clinical series of hips after arthroscopic anterior inferior iliac spine/subspine decompression.

PURPOSE: The purposes of this study were to define the anatomy of the anterior inferior iliac spine (AIIS) and its relation to the footprint of the rectus femoris tendon and to evaluate on the clinical outcomes after AIIS/subspine decompression. METHODS: The rectus origin was dissected and detached in 11 male cadaveric hips with a mean age of 54.3 ± 14.3 years (range, 33 to 74 years). The proximal-distal and medial-lateral extent of the footprint and its relation to the AIIS and acetabular rim were evaluated, with the 12-o'clock position defined as directly lateral at the insertion of the indirect head of the rectus tendon and the 1- to 6-o'clock positions defined as anterior acetabular positions. To assess the safety and efficacy of subspine decompression for AIIS deformity, clinical correlation of a series of 163 AIIS decompressions (mean age, 27.8 years; age range, 14 to 52 years) performed from January 2011 to January 2012 was completed, and outcome scores, strength deficits, and ruptures were assessed by manual muscle testing and postoperative radiographs. All patients presented with symptomatic FAI with proximal femoral and/or acetabular deformity and type 2 (131 hips) or type 3 (32 hips) AIIS morphology as defined by Hetsroni et al. RESULTS: The mean proximal-distal and medial-lateral distances for the rectus origin footprint were 2.2 ± 0.1 cm (range, 2.1 to 2.4 cm) and 1.6 ± 0.3 cm (range, 1.2 to 2.3 cm), respectively. There was a characteristic bare area at the anteromedial AIIS. On the clock face, the lateral margin (1-o'clock to 1:30 position) and medial margin (2-o'clock to 2:30 position) of the AIIS and the indirect head of the rectus (12 o'clock) were consistent for all specimens. In the clinical series, 163 AIIS decompressions were performed for symptomatic subspine impingement. The mean modified Harris Hip Score was 63.1 points (range, 21 to 90 points) preoperatively compared with 85.3 points (range, 37 to 100 points) at a mean follow-up of 11.1 ± 4.1 months (range, 6 to 24 months) (P < .01). Short Form 12 scores improved significantly from a mean of 70.4 (range, 34 to 93) preoperatively to a mean of 81.3 (range, 31 to 99) postoperatively (P < .01). The mean pain score on a visual analog scale also improved significantly from a mean of 4.9 (range, 0.1 to 8.6) preoperatively to a mean of 1.9 (range, 0 to 7.8) postoperatively (P < .01). The mean alpha angle improved from 61.5° (range, 35° to 90°) preoperatively to 49° (range, 35° to 63°) postoperatively on anteroposterior radiographs and from 71° (range, 45° to 90°) preoperatively to 44.3° (range, 37° to 60°) postoperatively on lateral radiographs. No short- or long-term hip flexion deficits or rectus femoris avulsions were noted with up to 2 years' follow-up. CONCLUSIONS: The origin of the rectus femoris tendon is broad on the AIIS and protective against direct head detachment with subspine decompression. This broad origin and consistent bare area anteromedially on the AIIS can be readily used by surgeons to perform a safe AIIS resection in cases of symptomatic impingement. Arthroscopic subspine decompression in addition to osteoplasty for symptomatic cam- and/or pincer-type FAI deformities can reliably improve outcome scores without significant hip flexion deficits or AIIS/rectus femoris avulsions. CLINICAL RELEVANCE: The direct head of the rectus tendon has a broad insertion on the AIIS, and an area devoid of tendon provides a "safe zone" for subspine decompression in cases of symptomatic AIIS impingement.

Can formation of avascular necrosis really be prevented in Delbet type 2 femoral neck fractures?

BACKGROUND: Fractures of proximal femur are rarely seen in childhood. These fractures can result in serious complications such as avascular necrosis (AVN), coxa vara, and early closure of the femoral epiphysis. The aim of this study is to investigate retrospectively the Delbet type 2 fractures that are commonly seen and has high rates of AVN. METHODS: Forty-two patients whose Delbet type 2 fractures were treated in our hospital between January 2009 and June 2018 were analyzed. The patients' mechanism of fracture formation, displacement of the fracture, presence of accompanying injuries, timing of surgery, open or closed reduction, whether the screws cross the epiphyseal growth plate epiphyseal line, and AVN data were analyzed retrospectively. RESULTS: Of the 42 screened patients, 34 patients with complete follow-up graphs and files were included in the study. The mean age of the patients was 11.02 years (1-17 years old), and the mean follow-up time was 40.82 months (range 24 to 98 months). When the follow-up radiographs of the patients were examined, it was found that AVN in 9 patients (26.5%), coxa vara in 2 patients (5.9%), and non-union in 1 patient (2.9%). The AVN rate was significantly higher in patients with high-energy injuries and high fracture displacement at baseline (p=0.034 and p=0.047, respectively). CONCLUSION: According to our findings in Delbet type 2 fractures, other than the severity of the trauma and the initial displacement of the fracture, factors related to the treatment process do not have a significant effect on the development of AVN. Age was not determined as a risk factor for the development of AVN in these patients.

A technical trick for extracting a stingray spine from hand: a case report.

Injuries from stingray fish are among the most common fish stings, and their frequency is increasing with the increase in global tourism. It most commonly causes injuries to the extremities and causes morbidity if not treated appropriately. Less commonly, life-threatening injuries can be observed due to injuries in the thorax and abdomen and damage to large vessels and vital organs. In addition to severe pain, tissue necrosis, and secondary infection after injury, systemic symptoms may occur. Since these injuries can occur in both fresh and salt water, it is possible to encounter such a case at any time. Flat spines are sharp, with backward barbs or serrations that make them difficult to extract once they penetrate tissue. After first aid, surgical extraction of the stingray spine with minimal damage is essential in addition to local and systemic treatments. In the literature, there are studies on envenomation and other systemic findings after stingray spine injuries, but few publications are available on the stingray spine extracted technique after injury. This case report presents a new and helpful technique for stingray spine extraction.

Can American Orthopaedic Foot and Ankle Society (AOFAS) score prevent unnecessary MRI in isolated ankle ligament injuries?

INTRODUCTION AND OBJECTIVE: Ankle injuries are the most common musculoskeletal injuries. Its incidence is also high among sports injuries. Direct X-ray, ultrasound and MRI can be requested after the history and physical examination in the patient who presents with ankle ligament injury. Some classifications are used for requesting direct X-ray after ankle injury. Since clear limits are not specified in the literature for MRI, the rate of unnecessary MRI examinations is high. We argue that the decision can be made according to the AOFAS score to be checked before MR is requested, and thus unnecessary MR requests can be reduced. MATERIAL AND METHOD: Ankle MRI images of patients who underwent ankle MRI due to ankle trauma between January 2018 and December 2020 were scanned. 328 patients who met the criteria were included in the study. Patients with AOFAS scores in their outpatient clinic records were identified. AOFAS scores of patients with at least one ligament injury and those with normal MR images were statistically compared. Sensitivity and specificity were determined for the AOFAS score using ROC analysis. RESULTS: Patients with ligament damage as a result of MRI examination were 21.3% (n=70), and patients without any ligament damage were 78.7% (n=258). There was a statistically significant difference in terms of AOFAS between the group with ligament damage and the group without ligament damage (p< 0.05). In the ROC analysis, the AOFAS threshold value for MR request was determined as 80.5 (84.3% sensitivity and 72.3% specificity). Based on the determined threshold value, 73 patients who had unnecessary MRI would have been eliminated, thus reducing the number of MRIs by 42.6%. CONCLUSION: The AOFAS scores of patients with ligament damage were statistically significantly lower than those of patients without ligament pathology. Unnecessary MRI can be significantly prevented by using the AOFAS score in ankle traumas without bone fractures.

Predictive factors for the development of Gartland type IV supracondylar humerus fractures: a prospective clinical study.

OBJECTIVE: This study aimed to identify the preoperative predictive factors for the development of Gartland type IV supracondylar humerus fracture based on the patient characteristic, fracture mechanism, and preoperative radiographic fracture characteristics. METHODS: This prospective study included the data of 120 patients with Gartland type III and IV supracondylar humerus fractures treated in a single center from 2020 to 2021. Patients' age, gender, height/weight percentile values, injury mechanisms, the proximity of fracture fragment to the skin (i.e., dimple sign), and time from trauma to surgical treatment were recorded. In the preoperative radiographs, the degree of extension or flexion deformity between fracture fragments in the sagittal plane, varus/valgus angulation between fracture fragments in the coronal plane, the amount of translation (medial or lateral) in the coronal plane, and the amount of osseous apposition between fracture fragments in the coronal plane were evaluated. With the authors' consensus, the patients were divided into 2 groups based on the presence of multidirectional instability during the intraoperative reduction: group 1 (Gartland type III; 99 patients) and group 2 (Gartland type IV; 21 patients). Fixation of the fractures was then completed. RESULTS: Significant differences were observed between groups in the valgus/varus angle and amount of osseous apposition (P < .001). Although no significant difference was found in terms of translation amount between the groups (P=.088), there was a significant correlation with medial translation in type IV fractures (P < .001). The correlation between the results and the groups was checked with Spearman's test. Medial translation (r=0.352), varus or valgus angulation (r=0.616), and osseous apposition (r=0.433) exhibited a positive correlation. The probability of type IV fracture was modeled for the preoperative parameters using binary logistic regression. The regression analysis showed that the diagnosis of type IV supracondylar fractures could be predicted, if varus or valgus angulation was more than 25.5° (81% sensitivity, 85% specificity, odds ratio=1.725; 95% CI=1.170-2.541, P=.001, r=0.616) and if the amount of osseous apposition was more than 9.5 mm (85% sensitivity, 81% specificity, odds ratio=1.471; 95% CI=0.714-3.029, P=.001, r=0.433) in the preoperative radiographs. There was also a significant correlation between medial translation (varus angulation) (P < .001, r=0.352), age (P=.019, r=0.255), and patients with more than 90 height/weight percentile values (P < .001, r=0.508) with the possibility to have Gartland type IV fractures. CONCLUSION: This study has found some preoperative factors that may be relevant for type IV Gartland fractures. Height/weight values greater than the 90 percentile, varus or valgus angulation greater than 25.5°, bone apposition values greater than 9.5mm, medial translation values greater than 11mm, and older than eight years patients type IV fractures were more common in such patients. If surgeons can more accurately diagnose a Gartland type IV fracture preoperatively, the surgeon can more accurately inform the patient and plan better treatment. LEVEL OF EVIDENCE: Level II, Diagnostic Study.

Periprosthetic infection risks and predictive value of C-reactive protein / albumin ratio for total joint arthroplasty.

BACKGROUND AND AIM: There are no gold standard markers to estimate the risk of developing periprosthetic infections. Our aim is to compare the risks of periprosthetic infection in patients with THA and THA and to investigate the predictive significance of the CRP / albumin ratio. METHODS: This is a retrospective study containing data from 241 osteoarthritis patients and 19 patients with periprosthetic infections who underwent TKA and THA in our hospital from January 2014 to January 2019.12 risk factors(CRP/ albumin, albumin, CRP, age, gender, BMI, DM, ASA, nasal culture, urine culture, hospital stay, operation time) were analyzed. RESULTS: In the binary logistic regression model and multivariate regression analysis, the rate of CRP / albumin was 17.161 times higher than the patients with ≤0.16 cut-off value. (CRP / albumin ratio (odds ratio (OR) = 17.16, 95% CI: 1.55-189.03, P: 0.02). High BMI increased the risk of periprosthetic infection 1.3 times. Nasal bacterial colonization (OR = 0.99, 95% CI: 0.868-1.38, P: 0.7) and bacterium in urine (OR = 0.502, 95% CI: 0.07-3.598, P: 0.703) did not pose a significant risk for periprosthetic infection. CONCLUSION: According to our findings, the CRP / albumin ratio has a more prognostic capacity than other risks in determining the risk of periprosthetic infection for total joint arthroplasty. CRP / albumin ratio is a cheap and easy to apply marker. Routine urine and nasal bacteria screening is not required before total joint arthroplasty.