Is it necessary to graft the void defect during open reduction and internal fixation of calcaneal fractures?

PURPOSE: There are still controversies on the effect of grafting during open reduction and internal fixation of calcaneal fractures. The aim of this study was to compare the radiological and functional outcomes in patients with or without intraoperative grafting. METHODS: In a comparative retrospective study, among 442 operatively-treated calcaneal fractures, 60 patients with unilateral closed sanders type II intraarticular calcaneal fracture who underwent ORIF via lateral extensile approach using locking anatomical plates with at least 1 year follow-up without any postoperative wound complication were enrolled. The patients were separated into 2 groups: with bone allograft and without bone allograft. The functional outcome of the patients was assessed using visual analog scale (VAS) for pain, the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, foot function index (FFI), and short-form (SF-36) health survey. Radiographic variables included Böhler angle, Gissane angle, calcaneal width, calcaneal height, and talar declination angle. Also, the differences (delta) of these values in comparison to the uninjured foot were calculated. RESULTS: The mean age was 39.1 ± 12.7 (range, 13-67) years with 54 males, 90.0%. No statistically significant differences were detected in age, gender, affected side, and subtypes of calcaneal fractures between the two groups (p > 0.05). The average follow-up was 25.1 (range, 12-48) months. The differences for all radiographic measurements and also, the delta values between the groups were not statistically significant, except talar declination angle which was more in cases without grafting (p = 0.007). Although the differences between the two groups regarding AOFAS ankle-hindfoot scale (p = 0.257), VAS for pain (p = 0.645), and FFI (p = 0.261) were not statistically significant; the group with bone graft experienced less pain (19.7 ± 22.0) than the other group (26.7 ± 22.8). The difference between the groups was not statistically significant (p = 0.87) according to the SF-36 questionnaire. CONCLUSIONS: Incorporating allografts into the void defects during ORIF of displaced intraarticular calcaneal fractures may not improve functional outcomes and recover postoperative radiological parameters. Therefore, routine use of allograft to fill the defects during ORIF of calcaneus may not be recommended. Of note, that these findings solely relate to the treatment of Sanders type II fractures. LEVEL OF EVIDENCE III: Comparative retrospective study.

Mechanical evaluation of the effect of the rod to rod distance on the stiffness of uniplanar external fixator frames.

PURPOSE: To investigate the effect of the rod-to-rod distance on the mechanical stability of single-rod and double-rod external fixator frames. METHODS:  Four different constructs, one single-rod and three double-rod constructs with different rod-rod distances, were subjected to the axial, bending, and torsional forces. The stiffness of different configurations was calculated. RESULTS:  Single-rod configuration had statistically the lowest stiffness when subjected to the axial, bending, and torsional forces. Maximum stiffness against the axial and anterior-posterior bending forces was achieved when the rod-rod distance was adjusted to 50 mm (halfway between the first rod and the end of the Schanz pins). There was no statistically significant difference in lateral bending stiffness among different double-rod configurations (p value: 0.435). The maximum stiffness against torsional forces was achieved when the rod-rod distance was adjusted to 100 mm (the second rod at the end of the Schanz pins). CONCLUSION:  Double-rod uniplanar external fixator frames are significantly stiffer than the single-rod constructs, and however, the rod-rod distance can significantly affect the construct stiffness. We found that a frame with 50 mm rod-rod distance was the optimum fixator among tested configurations that allowed a balance between axial, bending, and torsional stiffness of the construct.

The impact of spino-pelvic parameters on pathogenesis of lumbar disc herniation.

PURPOSE: Controversies exist on the relative contribution of sagittal spino-pelvic alignment on pathogenesis of lumbar disc herniation. METHODS: Spinopelvic alignment parameters, pelvic incidence, pelvic tilt, sacral slope, pelvic radius-S1 end-plate ratio and pelvic radius-S1 angle, in 52 patients with lumbar disc herniation were compared with the same measurements in 43 healthy adult volunteers. RESULTS: Statistical analysis revealed significant difference in pelvic incidence and sacral slope between patients with lumbar disc herniation and normal population. CONCLUSION: Patients with lumbar disc herniation have a more vertical sacrum compared to the normal population which may result in higher intradiscal pressure in these patients.

Conservative or surgical treatment of carpal tunnel syndrome based on the severity and patient risk factors.

BACKGROUND: The carpal tunnel syndrome (CTS) is the most common median nerve compression disease which may result in impaired nerve function. This study was carried out to determine which treatment is more appropriate for moderate or severe CTS patients with or without risk factors. MATERIALS AND METHODS: In a cohort prospective study, the patients with moderate CTS received a conservative treatment including night splint for 3 months, one methyl prednisolone injection whereas patients with severe CTS underwent surgical release. They were followed for 1 year using the bland scale based on the electromyography and nerve conduction velocity studies and five-point global assessment outcome scale. RESULTS: Totally, 68 moderate CTS cases (32 patients with risk factors and 36 without any risk factors) and 32 cases with severe CTS (16 patients with risk factors and 16 without any risk factors) were assess at 6 months and 1 year following the treatment. Although about 22% of moderate CTS patients with risk factors changed to mild CTS after 6 months of conservative treatment, about 75% showed mild CTS or complete remedy following 1 year (P value < 0.001). This result was about 30% at 6 months and about 95% at 1 year following conservative treatment in patients with moderate CTS without risk factors. None of moderate CTS patients with or without risk factors underwent surgery after 1 year of follow-up. Although almost all patients with severe CTS, with and without risk factors, showed complete recovery or changed to mild CTS at 1 year postoperatively, the result was statistically significant for cases without risk factors (P value = 0.002). CONCLUSION: Conservative treatment for moderate CTS would be a good option, and the final result may be seen 1 year later; however, its positive effect is quicker and better for moderate CTS cases without risk factors. Surgical release of the carpal tunnel may be the best choice not only for severe CTS cases with risk factors but also for cases without risk factors. For obtaining consistent rapid result, it is recommended to do surgical release for all cases of moderate or severe CTS without considering risk factors, but more clinical researches are needed. LEVEL OF EVIDENCE: II.

Concomitant Traumatic Peroneal Tendon Dislocation and Medial Malleolus Fracture: A Case Report.

Peroneal tendon dislocation in association with medial malleolus fracture is a very rare traumatic injury to the ankle. A 19-year old male patient was referred after injury sustained in a motorcycle accident with car, with concomitant traumatic peroneal tendon dislocation and medial malleolus fracture. The possible mechanism of this unusual injury could have been sudden external rotation force to the pronated foot in full dorsiflexed position of the ankle. Diagnosis of peroneal tendon subluxation or dislocation should be carefully evaluated in patients with single medial malleolus fracture.

Factors increasing mortality of the elderly following hip fracture surgery: role of body mass index, age, and smoking.

OBJECTIVES: Hip fracture is one of the most common public health problems with a significant financial burden on the patient and on the healthcare system. This study was conducted to assess the 3-month and 1-year mortality rates of patients with operated hip fractures and to determine the influence of predictors of mortality. METHODS: In this prospective cross-sectional study, all admitted patients aged more than 50 years with hip fracture at Chamran Hospital from January 2008 to August 2013 were enrolled. The characteristic data obtained included demographic information, body mass index (BMI), smoking, any previous history of osteoporotic fracture, and comorbidities. In addition, the mechanism of fracture, fracture type, and treatment method were recorded. A follow-up with the patients was conducted at 3 months and 1 year through a telephonic interview to ask about possible mortalities. Statistical analyses were performed using SPSS software version 17.0 for Windows. RESULTS: A total of 1015 patients aged 50 years and older with hip fracture underwent surgery. Only 724 patients (71.3 %) completed the survey and the 1-year follow-up interview. The mean age was 75.7 ± 10.6 years. Overall, the 3-month and 1-year mortality rates were 14.5 and 22.4 %, respectively. Multivariate logistic regression analysis recognized age (OR 1.08; 95 % CI 1.05, 1.11, p < 0.001), BMI (OR 0.88; 95 % CI 0.82, 0.96, p = 0.003), and smoking (OR 1.76; 95 % CI 1.05, 2.96, p = 0.03) as major independent risk factors for mortality. CONCLUSION: It is clear that modifiable factors like quitting the habit of smoking and gaining more energy with better nutrition could reduce the mortality rate if hip fracture occurs in the elderly.

Outcome of arthroscopic single-bundle anterior cruciate ligament reconstruction: anteromedial portal technique versus transtibial drilling technique.

PURPOSE: Controversies exist about the femoral tunnel preparation technique in anterior cruciate ligament (ACL) reconstruction surgeries. The aim of this study was to evaluate mid-term outcomes of transtibial (TT) technique in comparison with anteromedial portal (AMP) one. METHODS: Demographic data, height, weight, period of time from injury to surgery, and follow-up duration of patients underwent ACL reconstruction using single-bundle hamstring graft by the senior author between 2007 and 2011 were evaluated, retrospectively. Mid-quadriceps circumference difference, passive range of motion of the joint, anterior drawer test, Lachman test, and pivot shift test were assessed for each case. Function of the knee joint was calculated using International Knee Documentation Committee (IKDC), Lysholm, and Tegner scores. RESULTS: Of 50 cases in the AMP group (age 30.6 ± 6.5), 45 were male and of the 44 patients in the TT group (age 30.0 ± 6.5), forty were male. Mean follow-up times in the AMP and TT group were 18.2 months (range 12-84 months) and 25.7 months (range 16-48 months), respectively. No statistically significant difference was found in mid-quadriceps circumference difference (P = 0.861). Also, functional knee scores (P values of IKDC = 0.329, Lysholm score = 0.08, Tegner = 0.504) and stability tests (P values of anterior drawer test = 0.07, Lachman test = 0.486, pivot shift test = 0.348) did not differ statistically between groups. CONCLUSION: There is no superiority of AMP technique on TT technique in ACL reconstructive surgeries. It could be suggested that performing a well-done technique, either TT or AMP, may be more important than only choosing a technique.

Results of fusion and instrumentation of thoracic and lumbar vertebral fractures in children: a prospective ten-year study.

BACKGROUND: Researches on the results of surgical treatment of thoracolumbar spine fractures are infrequent. The aim of this study was to determine midterm outcomes of surgical treatment of these fractures in a prospective survey. METHODS: A case series study on pediatric patients with the diagnosis of thoracic and/or lumbar vertebral fractures was conducted over a ten-year period. Surgically treated patients were evaluated in the follow-up period, based on back pain, independent function, neurological status, and radiographic indices. RESULTS: There were 102 pediatric individuals, 61 boys and 41 girls, aged 3-17 years (mean 12 years of age) with thoracic and/or lumbar spinal fractures. Motor vehicle accident was the most common mechanism of injury (45.0 %). L1 was the most frequent level of fractured vertebra (24.4 %), and pelvic fracture was the most common associated orthopedic injury (21.5 %). Totally, 20 patients underwent surgery, but only fifteen (14 boys and one girl) participated in follow-up (mean 49 months; range 12-81 months). Posterior spinal fusion and instrumentation was accomplished in 12 cases. Three patients were operated by anterior approach and fusion followed by posterior fusion and instrumentation because of delay in diagnosis. There were no major perioperative complications. Two cauda equina syndromes and two incomplete spinal cord injuries improved back to normal. Five cases (33.3 %) reported occasional back pain, and all patients were functionally independent. Radiographic indices improved significantly. CONCLUSIONS: Spinal fusion and instrumentation in pediatric patients with unstable thoracolumbar vertebral fractures with or without spinal cord injuries have favorable radiographic and functional outcomes.

Prevention of arthrofibrosis by monoclonal antibody against vascular endothelial growth factor: a novel use of bevacizumab in rabbits.

BACKGROUND: Prevention of arthrofibrosis by different drugs and surgical techniques is an essential issue in modern orthopedics. HYPOTHESIS: Intra-articular injection of bevacizumab can reduce arthrofibrosis on the rabbit's stifle joint model. MATERIALS AND METHODS: Arthrofibrosis was induced in the right stifle joint of thirty male New Zealand white rabbits by removing the cortical bone of the medial femoral condyle under general anesthesia. The rabbits were randomly divided into three equal groups. The control group received intra-articular injection of saline; the one-injection group received a single dose of bevacizumab (2.5mg/kg), and the two-injection group received two intra-articular injections; the operation day and 14 days later. Forty-five days after surgery, animals were sacrificed. The severity of fibrosis was assessed based on the range of motion of the joint, a macroscopic adhesion score, and histopathologic variables such as the number of fibroblasts and of inflammatory cells, collagenous matrix deposition, synovial hyperplasia, granulation tissue formation, vascular proliferation, and presence of giant cells. RESULTS: Although no statistically significant differences were found between the range of motion (P=0.222) and the macroscopic evaluation (P=0.067) of the control group and the one-injection group, all microscopic variables regarding the prevention of arthrofibrosis were significantly superior in the one-injection group except granulation tissue (P=0.347). Compared to the one-injection group, the two-injection group had better results not only in terms of macroscopic evaluation (P=0.001 for range of motion and 0.012 for visual adhesion score) but also in most of the histopathologic variables especially the number of fibroblasts (P=0.002), vascularity (P=0.028) and collagenous matrix deposition (P=0.039). CONCLUSION: A single intra-articular injection of bevacizumab was effective for prevention of microscopically detected arthrofibrosis in the rabbit. Compared to single injection, two injections of bevacizumab improved the clinical outcome. LEVEL OF EVIDENCE: Level II.