Mortality Factors in Crush Syndrome.

BACKGROUND: Crush Syndrome is a major cause of morbidity and mortality following large-scale catastrophic earthquakes. Since there are no randomized controlled studies on Crush Syndrome, knowledge on this subject is limited to expert experience. The primary objective is to analyze the epidemiological and demographic characteristics, clinical outcomes, and mortality factors of earthquake victims after the Pazarcik and Elbistan earthquakes on February 6, 2023. METHODS: This cross-sectional and observational retrospective study evaluated 610 earthquake victims who presented to our center between February 6 and April 30, 2023. Among these patients, 128 with Crush Syndrome were included in the study. Patient information was gathered from hospital records during their stay and from national registries upon referral. The primary outcome was to identify risk factors for mortality. Demographic and laboratory data were analyzed by acute kidney injury (AKI) stages; mortality-affecting factors were identified through regression analysis. RESULTS: Of the 128 Crush Syndrome patients (100 adults, 28 children), 64 were female. The AKI rate was 32.8%. Among patients with AKI, the frequency of hemodialysis requirement was 69%, and the mortality rate was 14.2%. The overall mortality rate for patients with Crush Syndrome was 4.6%, compared to 3.9% (19/482) in earthquake victims without Crush Syndrome (p=0.705). Notably, low systolic blood pressure at admission was the only factor significantly affecting mortality in Crush Syndrome patients (Hazard Ratio [HR]: 1.088, p=0.021, 95% Confidence Interval [CI]). CONCLUSION: Our study highlights low systolic blood pressure upon admission as a significant risk factor for increased mortality in Crush Syndrome patients. This finding may contribute to the literature by emphasizing the importance of monitoring blood pressure under rubble and administering more aggressive fluid therapy to patients with low systolic blood pressure.

Effectiveness of simultaneous umbilical hernia primary repair with laparoscopic cholecystectomy.

OBJECTIVE: Umbilical hernia repair can be easily performed simultaneously with laparoscopic cholecystectomy. The use of mesh is recommended for hernias larger than 1 cm. In this study, patients with primary repair of umbilical hernia simultaneously with laparoscopic cholecystectomy were evaluated. It aimed to present the effectiveness of this method and the effect of body mass index (BMI) on treatment results. METHODS: The records of patients who underwent primary repair of umbilical hernia simultaneously with laparoscopic cholecystectomy between 2014 and 2021 were reviewed retrospectively. Patients' age, gender, BMI, length of hospital stay, recurrence and reoperation information, and follow-up times were analyzed. The patients were examined in three groups according to their BMI, and the effect of BMI on treatment was investigated. RESULTS: patients were included in the study. Median values of the patients for age, BMI, hospitalization, and follow-up were 63 (28-94), 31 (20-51) kg/m2, 1 (1-25) days, and 23 (0.6-76) months, respectively. Recurrence was detected in 8 patients. BMI was <25 in one patient with recurrence and >30 in 5 patients. There was no significant correlation between length of stay, number of relapse and reoperation, and BMI (p>0.05). CONCLUSION: In our study, the recurrence rate was found to be higher than the studies reported with the use of mesh, and most of the patients with recurrence are obese, although it is not statistically significant. If the recurrence rate is acceptable, we believe that repair with primary suture is feasible in umbilical hernia.

Factors Affecting Recurrence of Idiopathic Granulomatous Mastitis.

OBJECTIVE: To investigate factors that may have an effect on recurrence by retrospectively analysing the data of patients who were followed up and treated for idiopathic granulomatous mastitis in this clinic. STUDY DESIGN: Analytic study. PLACE AND DURATION OF STUDY: Department of General Surgery, Faculty of Medicine, Baskent University, Konya and Adana Practice and Research Hospitals between January 2010 and January 2021. METHODOLOGY: The data of patients who were histopathologically diagnosed with granulomatous mastitis were retrospectively analysed. The patients included in the study were divided into two groups: Recurrence (Group 1) and non-recurrence (Group 2). Patients with underlying etiological factors that may cause granulomatous inflammation such as infection, trauma, tuberculosis, sarcoidosis, and autoimmune disease were excluded from the study. The effects of other parameters (involvement area, follow-up duration, the time from the onset of complaints to diagnosis, side of involvement, breastfeeding, oral contraceptive use, redness, ulceration and/or discharge, preoperative histopathological diagnosis, diagnosis by any of the preoperative imaging techniques, preferred treatment method) on recurrence, were statistically analysed. RESULTS: Furthermore, the analysis results showed no significant difference between the groups with and without recurrence with regard to any of the other variables such as follow-up period, size of the involvement area, presenting complaints, breast-feeding, preferred treatment alternative (steroid, steroid + surgery, surgery), and preferred surgical technique (p>0.05). The time from the onset of complaints to diagnosis was significantly longer in the recurrence group (p=0.001). In addition, the frequency of oral contraceptive use was statistically significantly higher in the recurrence group (Odds ratio=7.6, p=0.044). CONCLUSION: The results of this study suggest that early diagnosis could prevent recurrence in patients with idiopathic granulomatous mastitis. Prospective randomised controlled studies are needed to support this thought. Key Words: Idiopathic granulomatous mastitis, Malignancy, Oral contraceptive, Steroid.

Comparison of Changes in SRS-22 Values with Improvement in Cobb Angles after Posterior Fusion Surgery in Adolescent Idiopathic Scoliosis.

INTRODUCTION: The purpose of this study was to evaluate the relationship between the correction rate in Cobb angle and the improvement in quality of life profile in terms of Scoliosis Research Society (SRS)-22 values. PATIENTS AND METHODS: Between January 2007 and December 2013, posterior instrumentation and fusion was performed to 30 patients with adolescent idiopathic scoliosis (AIS). Patients were grouped according to their improvement rate in Cobb angles after surgery. Patients with an improvement rate of > 80% were grouped as Group A; those with an improvement rate of > 60% and ≤ 80% as Group B and those with an improvement rate of ≤ 60% were grouped as Group C. The SRS-22 questionnaire of these three groups was calculated and their relationship with the improvement in Cobb angle was evaluated. RESULTS: No statistical difference was found among the three groups in terms of pain, appearance, function, spirit, satisfaction, and SRS-22 values (all p > 0.05). CONCLUSION: The results of this study demonstrate that the degree of correction rate does not correlate with the degree of improvement in the SRS-22 questionnaire in patients with AIS that underwent posterior fusion and instrumentation.

Traumatic spinopelvic dissociation managed with bilateral triangular osteosynthesis: Functional and radiological outcomes, health related quality of life and complication rates.

BACKGROUND: Spinopelvic dissociation (SPD) is difficult to manage and is associated with high mortality and morbidity, including concomitant orthopaedic polytrauma, spine injuries, pelvic ring disruptions, neurological, soft-tissue, and vascular injuries. The purpose of this study is to evaluate the functional and radiological outcomes; health related quality of life and complication rates of patients with traumatic spinopelvic dissociation underwent bilateral triangular osteosynthesis (TOS). METHODS: The study was approved by the medical school's institutional review board (IRB). Prospective data collection of nineteen consecutive cases of traumatic SPD were included in the study from October 2015 to August 2018. Bilateral TOS was performed to manage all patients with SPD. The clinical outcome for fractures was analyzed with Majeed function assessment. Health Related Quality of Life (HRQoL) was assessed with the EQ-6D questionnaire. The reduction quality was evaluated according to Matta criterion. CT scanning was used to verify the fracture union in patients at 24th weeks postoperatively. RESULTS: There were 12 women and 7 men with an average age of 47.2±8.4 years (range, 17-62 years). The average follow-up time was 25.2±3.7 months (average, 22-45 months). The most common mechanism of injury was falling (57%). According to Majeed functional scoring, the results were excellent in 12 cases, good in 5 cases and fair in 2 cases. The median EQVAS score was 78.9±8.4. 15 patients (78.9%) turned back to their original occupation. Pain and mood disorders mainly influenced patients' present general health status. According to Matta criterion for fracture reduction, the results were excellent in 14 cases, good in 4 cases and fair in 1 case. Complications were noted as wound healing problems (26%), implant loosening (5%) and iatrogenic nerve injury (5%). CONCLUSION: Bilateral TOS demonstrates satisfactory functional and radiological outcomes with low complication rates except infection rate in patients with traumatic spinopelvic dissociation. HRQoL is mainly dominated by pain and mood disorders. 78.9% of the patients turned back to their original occupation. Surgeons should be aware of wound healing problems in case of increased muscle mobilization and degloving injuries.Implant removal is required to improve the lumbopelvic mobility.

Clinical and radiological outcomes of chronic severe slipped capital femoral epiphysis patients treated by surgical dislocation and modified Dunn osteotomy: Case series.

OBJECTIVES: This study aims to evaluate the clinical and radiological outcomes of patients with chronic severe slipped capital femoral epiphysis (SCFE) treated by surgical dislocation and modified Dunn osteotomy (MDO). PATIENTS AND METHODS: This retrospective study, conducted between January 2010 and December 2017, included nine patients (8 males, 1 female; mean age 12.6 years; range, 7 to 16 years) with nine hips. The degree of corrections in Southwick angle and alpha angle were measured on frog-leg views. Range of motion (ROM) of the hips was measured at each follow-up visit. Heyman and Herndon classification system and Harris Hip Score (HHS) were evaluated for clinical and functional outcomes at the latest follow-up visit. RESULTS: The mean follow-up time was 34.8 months. Avascular necrosis complication was observed in one hip. Except two patients with lateral femoral cutaneous neuropathy, none of the patients suffered from any other complications. Mean preoperative Southwick angle of 59.1° was corrected to an angle of -0.8° postoperatively. Alpha angles were calculated as 44.6° postoperatively. Modified Dunn osteotomy resulted in marked improvement in hip ROM in all directions and increased HHS. CONCLUSION: Our results encourage us to use this method in treating SCFE patients with chronic severe slips.

Clinical perineural invasion of the trigeminal and facial nerves in cutaneous head and neck squamous cell carcinoma: Outcomes and prognostic implications of multimodality and salvage treatment.

BACKGROUND: Clinical perineural invasion (PNI) of the trigeminal and facial nerves from cutaneous head and neck squamous cell carcinoma (cutaneous HNSCC) is a rare clinical entity that poses unique therapeutic challenges. METHODS: A retrospective chart review of a skull base oncology database was performed of patients with the diagnosis of clinical PNI from a cutaneous HNSCC. Patients who were previously untreated underwent multimodal treatment entailing surgical resection and postoperative radiotherapy (PORT) and patients who were previously treated with radiotherapy underwent salvage surgical resection between the years 2006 and 2012. Survival outcomes, such as disease-free survival (DFS) and overall survival (OS), were analyzed and correlated with surgical factors, such as margin status, previous treatment, zone involvement, and trigeminal involvement (branch-specific), as well as the pretreatment and posttreatment pain scores. RESULTS: Of 21 patients with clinical PNI from cutaneous HNSCC, 7 patients (33%) were previously treated for their disease with primary radiotherapy. Negative tumor margins were achieved in 18 patients (86%). Three of the 7 patients (43%) undergoing salvage surgery had positive margins. One-year and 3-year DFS for previously untreated patients was 91% and 67%, respectively, whereas 1-year and 3-year DFS was 72% and 28%, respectively, for the previously treated patients. Previous radiotherapy, ophthalmic nerve involvement, and positive margins portended poorer survival outcomes in this study. CONCLUSION: The retrospective study of this rare clinical entity demonstrates that multimodal treatment can achieve favorable survival outcomes. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1280-1286, 2017.

Leiomyosarcoma of great saphenous vein localised to the calf.

We present the case of a 76-year-old man with a 2-month history of mildly tender swelling in the right calf for which he had an initial excision and then a wide local excision followed by a split skin graft because the initial histopathology confirmed that there was a Grade I leiomyosarcoma of great saphenous vein. A simple lump in the lower limb could be a malignant vascular tumour and should always be considered in the list of differential diagnosis of a lump in the lower limb.

Sunitinib as Neoadjuvant Chemotherapy in the Management of Metastatic Renal Cell Carcinoma Mimicking a Glomus Vagale Tumor in the Head and Neck: A Case Report and Review of Literature.

Background Metastatic renal cell carcinoma (RCC) of the head and neck with intracranial extension is rare and may pose difficulties to the diagnosis and management. Method We describe a unique case of a 76-year-old man with a metastatic RCC to the neck and lateral skull base with intracranial extension presenting with Collet-Sicard syndrome 8 years after initial diagnosis. The radiologic features were consistent with the diagnosis of a glomus vagale tumor on the basis of clinical and radiologic features. Results Despite radiotherapy, the intracranial extension progressed in size, resulting in early hydrocephalus. Sunitinib, a novel tyrosine kinase inhibitor, was instituted to treat the glomus vagale tumor with a marked reduction in tumor volume and resolution of the early hydrocephalus. The surgical resection of the tumor with its intracranial extension was achieved without additional postoperative morbidity. The histopathologic diagnosis surprisingly demonstrated metastatic RCC. Conclusion We present a case of metastatic RCC to the head and neck region mimicking a glomus vagale tumor and describe the first use of sunitinib as a neoadjuvant chemotherapy to achieve a single-stage radical en bloc resection of the tumor mass.

En Bloc Resection of Desmoplastic Neurotropic Melanoma with Perineural Invasion of the Intracranial Trigeminal and Intraparotid Facial Nerve: Case Report and Review of the Literature.

Background Desmoplastic neurotropic melanoma (DNM) is a rare, highly malignant, and locally invasive form of cutaneous melanoma with a tendency for perineural invasion (PNI). Methods We report a case of a 61-year-old man presenting with right-sided trigeminal neuralgia and progressive facial paresis due to the PNI of the intracranial trigeminal nerve and the intraparotid facial nerve from DNM. We also present a review of the literature with six cases of DNM with PNI of the intracranial trigeminal nerve identified. Results The combined transtemporal-infratemporal fossa approach was performed to achieve total en bloc resection of the tumor mass followed by postoperative radiotherapy (PORT). After 24 months of follow-up, the patient remains disease free with no signs of recurrence on magnetic resonance imaging. Conclusion We recommend the en bloc resection of the tumor mass followed by PORT for the management of DNM with PNI. A high index of suspicion for PNI as a cause of cranial neuropathies is essential for the early detection and treatment of patients with known melanoma.

The analysis of functional and radiographic outcomes of conservative treatment in patients with low lumbar burst fractures.

INTRODUCTION: Burst fractures of the low lumbar spine constitute approximately one percent of all lumbar fractures. There is still no consensus on the optimal treatment of low lumbar burst factures. We aimed to evaluate the functional and radiographic outcomes of conservative treatment in patients with low lumbar burst fracture. METHODS: 15 patients (11 males, 4 females; mean age 32±8) who had low lumbar spine burst fracture treated with a custom-moulded thoracolumbosacral orthosis (TLSO) with a thigh extension were enrolled. The mean follow-up period was 22±6 months. 14 patients were neurologically intact and one had isolated nerve root injury. There were 24% type A fractures and 76% type B fractures according to the Denis classification system. Functional outcomes were evaluated by using Oswestry Disability Index (ODI), Short-Form 36 (SF-36) and Visual Analogue Scale (VAS). Radiographic outcome was analyzed by measuring anterior vertebral height loss, kyphosis angle, amount of canal retropulsion. Functional and radiographic outcomes were reviewed initially and at 1, 3, 6, 12 months, and at the latest follow-up. Functional and radiographic improvements were analyzed statistically. RESULTS: The mean bracing period was 11.9±1.7 weeks. The mean initial ODI, SF-36, and VAS score of the patients was 78.3±9.6, 23.7±8.9, and 8.7±0.7, respectively. The mean ODI, SF-36, and VAS score of the patients at the final follow-up was 26.4±6.5, 68.1±11.2, and 2.8±1.7, respectively. The improvement in functional outcomes was measured to be significant (p<0.05 for ODI, SF-36 and VAS). The mean initial anterior vertebral height loss, kyphosis angle, amount of canal retropulsion was found to be 27.2%±9.6%, -6.8°±3.2°, 37.4%±10.2%, respectively. The mean anterior vertebral height loss, kyphosis angle, and amount of canal retropulsion at the final follow-up was 23.1%±.6.7%, -4.2°±2.4°, 19.6%±7.7%, respectively. Among the radiographic outcomes, only the amount of canal retropulsion improved statistically (p=0.042). CONCLUSION: Conservative treatment using a custom-moulded thoracolumbosacral orthosis with a thigh extension is a safe and effective method in patients with low lumbar spine burst fractures and can improve functional and radiographic outcomes.

Scaphoid nonunion treated with vascularised bone graft from dorsal radius.

INTRODUCTION: The main aim of this retrospective study was to present our experience on scaphoid nonunion treated with vascularised bone graft. METHODS: Between 2006 and 2012, 58 patients presenting with symptomatic scaphoid nonunion were eligible to participate in this study. Topography of the nonunion included 29 proximal, 25 waist and 4 distal scaphoid nonunions. Vascularised bone graft from distal dorsal radius was used in all cases which were stabilised with the headless cannulated compression screws. Scapholunate angles, Natrass carpal height ratio were evaluated pre and postoperatively. Range of motion of the affected side was compared to that of the contralateral side after the surgery. RESULTS: Radiographic union was achieved in 50, out of 58 cases with an average time of 9.9 weeks (range, 6-18 weeks). Out of all the non-united cases, four of them were in proximal, three in the waist and one was in distal scaphoid. In nine proximal nonunions treated by 4+5 ECA graft all but one were united. The mean follow up was 21.7 months (12-62 months). The flexion was 91.6%, the extension was 91.5%, the radial deviation was 81.2%, and the ulnar deviation was 89.5% compared to the other side. The grip strength was 93%. Preoperative DASH score was 61.5 diminishing to 28.7 postoperatively. There was no significant change in Natrass carpal height ratio but a slight improvement occurred in scapholunate angles both pre and postoperatively. CONCLUSION: Vascularised bone graft is a good solution for scaphoid nonunion to enhance the healing rate especially in the presence of avascular necrosis. Proximal pole nonunions, humpback deformity and smoking are important negative factors for scaphoid nonunion despite the use of a vascularised bone graft. A trapezoidal wedge graft is necessary for the volar type nonunions with humpback deformity. 1,2 ICSRA offer an advantage with its proximity to scaphoid in all nonunion locations. Nonetheless, 4+5 ECA graft is also a good solution for proximal nonunions.

Should full threaded compression screws be used in adult femoral neck fractures?

INTRODUCTION: Operative treatment consisting of fracture reduction and fixation, or arthroplasty to permit early patient mobilization, continues to be the treatment of choice for most femoral neck fractures. Options for internal fixation have included a variety of implants; however most recent reports and textbooks cite parallel multiple cancellous screws as the surgical technique of choice. METHODS: The study was prospective, randomized and IRB approved. Inclusion criteria included skeletal maturity, closed femoral neck fracture without concomitant fractures or injuries with complete charts and adequate radiographs obtained from the initial injury till the last follow-up. Forty-four patients were enrolled in this study during one-year period at two university centers. 22 were randomized to be treated with full threaded, cannulated compression screws (Acutrak 6/7, ACUMED) (Group 1) and the other 22 with 16mm partial threaded, 6.5mm or 7.3mm cannulated screws (SYNTHES) (Group 2). Three or four screws were used in both groups according to fracture type and surgeon's preference. Data evaluated included surgical time, fluoroscopy time, fracture type, radiological outcome, complications and functional status using the Harris Hip Score. RESULTS: Both groups were comparable in terms of age and gender. There was not a significant difference in terms of surgical time, follow-up period, fracture type, or fluoroscopy time. There were eight complications in Group 1 and two in Group 2 (P=0.049) Time to union was significantly longer in Group 1 (P=0.001). However, Hip Scores were not significantly different in both groups (P=0.20). CONCLUSION: When compared with full threaded compression screws, partial-threaded cannulated screws provides a shorter union time and less complication rate while providing equivalent functional results in adult femoral neck fractures.

Spinal cord injury from electrocautery: observations in a porcine model using electromyography and motor evoked potentials.

We have previously investigated electromyographic (EMG) and transcranial motor evoked potential (MEP) abnormalities after mechanical spinal cord injury. We now report thermally generated porcine spinal cord injury, characterized by spinal cord generated hindlimb EMG injury activity and spinal cord motor conduction block (MEP loss). Electrocautery (EC) was delivered to thoracic level dural root sleeves within 6-8 mm of the spinal cord (n = 6). Temperature recordings were made near the spinal cord. EMG and MEP were recorded by multiple gluteobiceps intramuscular electrodes before, during, and after EC. Duration of EC was titrated to an end-point of spinal motor conduction block (MEP loss). In 5/6 roots, ipsilateral EMG injury activity was induced by EC. In 4/5 roots, EMG injury activity was identified before MEP loss. In all roots, a minimum of 20 s EC and a temperature maximum of at least 57 °C at the dural root sleeve were required to induce MEP loss. Unexpectedly, conduction block was preceded by an enhanced MEP in 4/6 trials. EMG injury activity, preceding MEP loss, can be seen during near spinal cord EC. Depolarization and facilitation of lumbar motor neurons by thermally excited descending spinal tracts likely explains both hindlimb EMG and an enhanced MEP signal (seen before conduction block) respectively. A thermal mechanism may play a role in some unexplained MEP losses during intraoperative monitoring. EMG recordings might help to detect abnormal discharges and forewarn the monitorist during both mechanical and thermal injury to the spinal cord.

Evaluation of injection techniques in the treatment of lateral epicondylitis: a prospective randomized clinical trial.

OBJECTIVE: We aimed to compare the efficacy of two different injection techniques of local corticosteroid and local anesthetic in the management of lateral epicondylitis. METHODS: This prospective study followed 80 consecutive patients who were diagnosed with lateral epicondylitis at our hospital outpatient clinic between 2005 and 2006. Patients were randomly assigned into two equal groups. Group 1 received a single injection of 1 ml betamethasone and 1 ml prilocaine on the lateral epicondyle at the point of maximum tenderness. Group 2 patients received an injection of the same drug mixture. Following the initial injection, the needle tip was redirected and reinserted down the bone approximately 30 to 40 times without emerging from the skin, creating a hematoma. Patients were evaluated with the Turkish version of the Disabilities of the Arm, Shoulder and Hand questionnaire before injection and at the final follow-up. The unpaired t-test and chi-square tests were used to compare results. RESULTS: Sixteen patients in Group 1 and 15 patients in Group 2 were lost during follow-up. The average follow-up period of the remaining 49 patients was 21.6 months. There were no significant differences between the two groups with regard to gender, age, follow-up period, symptom duration, involvement side and number of dominant limbs. The Turkish DASH scores of Group 2 were significantly lower than those of Group 1 (p=0.017). CONCLUSION: Long-term clinical success in the treatment of lateral epicondylitis depends on the injection method. The peppering technique appears to be more effective than the single injection technique in the long-term.

Factors affecting isokinetic muscle strength before and after anterior cruciate ligament reconstruction.

The purpose of this study was to evaluate the factors affecting muscle strength of ACL-deficient knees before and after ACL reconstruction. The study included 122 male patients who underwent primary ACL reconstruction with a bone-patellar tendon-bone autograft. Preoperative loss and change in muscle strength in both extensor and flexor muscle groups after ACL reconstruction were calculated separately at 60 degrees/sec and 180 degrees/sec angular velocities. We evaluated the effect of surgical delay on the preoperative deficit and on its change after surgery. Muscle strength change after ACL reconstruction was also evaluated in relation to patient compliance to treatment. The longer the delay of ACL reconstruction the more the muscle strength deficit of flexor and extensor muscles increased. In the ACL deficient knees with high strength deficit, improvement in muscle strength was higher after ACL reconstruction for both muscle groups. When delay of ACL reconstruction was short and the patient was compliant to treatment, flexor muscle strength recovery was early. Shortening the delay to reconstruction had a positive influence on muscle strength after ACL reconstruction when preoperative muscle strength deficit was high.

A novel technique for reconstruction of the medial patellofemoral ligament in skeletally immature patients.

Habitual or recurrent dislocation of the patella in the skeletally immature patient is a particularly demanding problem since the etiology is frequently multifactorial. The surgical techniques successfully performed in adults with patellar instability may risk injury to an open growth plate if applied to children. We present a technique that preserves femoral and patellar insertion anatomy of medial patellofemoral ligament (MPFL) using a free semitendinosus autograft together with tenodesis to the adductor magnus tendon without damaging open physis on the patellar attachment of MPFL. A 3-cm long longitudinal skin incision is performed 10 mm distal to the tibial tuberosity on the anteromedial side. The semitendinosus tendon is harvested with the stripper. The semitendinosus tendon is placed on a preparation board and cleaned of muscle tissue. The usable part of the tendon should be at least 20 cm long and 4 mm wide. The two free ends of the graft are sutured with Krakow technique. A medial longitudinal incision 2 cm in length is made to expose the MPFL and to abrade the patellar attachment of vastus medialis obliquus. The first patellar tunnel is created with 4.5 mm drill at the mid aspect of the medial patella in the anteroposterior and proximal-distal direction. The drill hole is formed parallel to the articular surface of the center of the patella. The second tunnel is created with 3.2 mm drill and the entry point is localized at the center of the patella. These two tunnels intersect to form a single tunnel. The semitendinosus autograft is run through the bone tunnel in the patella. Double-stranded semitendinosus autograft is placed in the presynovial fatty plane between the second and the third layer of the medial retinaculum, and tenodesis to adductor magnus tendon is applied by a moderate medial force with the knee flexed at 30°. Aftercare includes immobilization of the joint limited to 30° flexion using an above-knee splint for 2 weeks. No recurrent dislocation was observed in three patients (4 knees) at a mean follow-up time of 17.7 months. Both range of motion and radiological finding were restored to normal limits.

[Factors causing stiff knee after total knee arthroplasty]. / Total diz artroplastisi sonrasi diz sertligine neden olan faktörler.

OBJECTIVES: In this study, the factors causing stiff knee after primary total knee arthroplasty (TKA) in patients with medial compartment osteoarthrosis were evaluated. PATIENTS AND METHODS: Primary TKA surgery was performed in fifty-three knees in 48 patients (42 females, 6 males; mean age 67.2±8.5; range 59 to 76 years) diagnosed with medial compartment osteoarthrosis. Five patients (10%) out of forty-eight underwent bilateral primary TKA. In the patients who had bilateral TKA, the second operation was performed six months later. Patello-femoral arthroplasty was performed in none of the patients. In the final follow-up, the knees, which had more than 10° of extension limitation and less than 95° of flexion, were defined as post-TKA stiff knee. The patients who developed stiff knee were classified as group 1 and the patients who did not develop stiff knee were classified as group 2. The possible factors that may cause stiff knee after TKA such as age, gender, range of knee flexion and extension, flexion arc, tibiofemoral angle, tibial slope angle, the change in the height of the joint line, the length of the patellar tendon, the change in the American Knee Society scores, body mass index, and the sizes and positions of the components were evaluated and compared pre- and postoperatively within and between both groups. RESULTS: Stiff knee was found in eight knees of six patients (16%) after TKA. In group 1, the mean extension range was 14.9°±4.6° and the mean flexion range was 82.6°±7.4°. In group 1, among the factors that may cause knee stiffness; preoperative flexion range and American Knee Society scores were found to be significant (p=0.028 and p=0.036, respectively). The American Knee Society scores were observed to be significantly lower in group 1 when compared to group 2 postoperatively (p=0.018). CONCLUSION: If the preoperative flexion range is limited and the American Knee Society scores are low, then the stiff knee is more likely to occur in patients who will undergo TKA. Age, gender, tibiofemoral angle, tibial slope angle, the change in the height of the joint line, the length of the patellar tendon, and the sizes and positions of the components have no significant effect on the development of stiff knee after TKA.

The effect on the pullout strength by the timing of pedicle screw insertion after calcium phosphate cement injection.

STUDY DESIGN: Biomechanical Cadaveric Study. OBJECTIVE: To characterize the pullout strength of calcium phosphate cement augmented screws between 0 and 6 minutes after cement injection. SUMMARY OF BACKGROUND DATA: Earlier studies with calcium phosphate cement on pedicle screws inserted into a metal mold or sawbone have shown that the augmentation strength can be affected by the time between cement injection and screw insertion. However, these studies only compared soft cement to completely hardened cement with extended waiting times. These extended waiting times are impractical in live spinal surgeries. METHODS: Twenty-four pedicle screws were inserted and pulled out axially from cadaveric bone to make revision models. The 24 screw holes were randomly divided into 4 groups, with each group having 6 holes. For each group, identical pedicle screws were inserted at 0, 2, 4, and 6 minutes after injection with bioresorbable calcium phosphate cement (CPC). After 24 hours, the augmented screws were pulled out axially and their pullout strengths were compared. RESULTS: The difference between secondary pullout strength and primary pullout strength increased up to 4 minutes after cement injection but decreased after 6 minutes but without statistical difference among the 4 time settings (P>0.3). CONCLUSIONS: The augmented screws had similar fixation strength regardless of the time between cement mixture and screw insertion as long as they are inserted within 6 minutes. Augmentation power tends to increase up to 4 minutes after cement injection but decreases after 6 minutes.

Biomechanical evaluation of a novel fenestrated pedicle screw augmented with bone cement in osteoporotic spines.

STUDY DESIGN: Comparative biomechanical study was conducted in osteoporotic human cadaveric spines. OBJECTIVE: Determine the influence of the volume of polymethyl methacrylate injected through a fenestrated pedicle screw on the pullout strength and on the ability to safely remove the implant. SUMMARY OF BACKGROUND DATA: Pedicle screw fixation in the osteoporotic spine can be improved by the addition of bone cement. Various injection techniques have been used. While improvement has been shown for the pullout strength, the optimal volume of cement to inject has not been previously studied. METHODS: Seven osteoporotic spines were instrumented with a standard and a fenestrated pedicle screw augmented with polymethyl methacrylate at each level (T7-L5). Three volumes of bone cement were randomly injected and stratified to the thoracic (0.5 cc, 1.0 cc, and 1.5 cc) and lumbar spine (1.5 cc, 2.0 cc, and 2.5 cc). Axial pullout strength and removal torque of the pedicle screws were quantified. RESULTS: The pullout strength of the fenestrated screw was normalized with respect to its contralateral control. Student paired t tests were conducted and a statistically significant increase was noted for 1.0 cc (186 ± 45%) and 1.5 cc (158 ± 46%) in the thoracic spine and for 1.5 cc (264 ± 193%), 2.0 cc (221 ± 93%), and 2.5 cc (198 ± 42%) in the lumbar spine. There was no significant difference with higher volumes of cement. The median removal torque was 0.34 Nm for the standard and 1.83 Nm for the augmented screws. When the augmented implants were removed, the bone cement sheared completely off at the fenestrations in 15 of the 17 cases. CONCLUSION: Significant increases in pullout strength can be accomplished by injecting a limited quantity of bone cement through a fenestrated screw while minimizing the risks associated with higher volume. The majority of implants were removed without damaging the vertebra as the bone cement sheared off at the fenestrations.