A Delphi consensus study on the treatment of slipped capital femoral epiphysis: Considerable consensus in mild and moderate slips and limited consensus in severe slips.

Purpose: The aim of this expert consensus study was to establish consensus on the treatment of different types of slipped capital femoral epiphysis and on the use of prophylactic screw fixation of the contralateral unaffected side. Methods: In this study, a four-round Delphi method was used. Questionnaires including all possible theoretical slip scenarios were sent online to 14 participants, experienced in the field of children's orthopedics and in the treatment of hip disorders in children. Results: In-situ fixation was considered to be the first treatment choice in all types of mild slip scenarios and in moderate, stable ones. Performing in-situ fixation was not favored in moderate, unstable, and in all severe slip scenarios. In moderate to severe, unstable slip scenarios, there was consensus on the use of gentle closed or open reduction and internal fixation. Any consensus was not established in the optimal treatment of severe, stable slips. There was also consensus on the use of prophylactic screw fixation of the contralateral side in case of co-existing endocrine disorder and younger age. Conclusions: The establishment of consensus on the treatment of all types of slipped capital femoral epiphysis even among the experienced surgeons does not seem to be possible. The severity of the slip and stability of the slip are the primary and secondary determinants of the surgeons' treatment choices, respectively. In-situ fixation is still the preferred treatment option in several slip types. Gentle capital realignment by closed or open means is recommended in displaced, unstable slips. Prophylactic screw fixation of the contralateral side is indicated under certain circumstances. Level of evidence: level V.

Anterior metaphyseal angle; much less individual variation in determining the posterior slope of the tibia.

BACKGROUND: The question of how to specify the posterior tilt of the tibia during arthroplasty operations remains unclear. The most current opinion is that a design whereby incisions are made in parallel with the individual pre-arthritic posterior tilt will yield better post-operational results. However, the wide range of inter-individual variations of posterior tilt of the tibia and the difficult task of identifying the shaft axis of the tibia through standard lateral radiographs are the main obstacles to this particular method. Therefore, there is a need for another reference line that can be measured with plain radiography and yields less inter-individual variation. The hypothesis of this study was that the angle formed between the anterior metaphyseal line of the proximal tibia and the tibial plateau would prove to be less variable across individuals. METHODS: Long-shot radiographs of non-rotating lateral tibias of 85 patients aged between 18 and 38 years were analysed. The angle forming between the anterior metaphyseal line of the proximal tibia and the slope of the tibial plateau, and the posterior slope angle was measured by 2 separate observers using the classical method. RESULTS: From the measurements of the posterior slope angle taken with the classical method, 38% (33/85) of the patients were within the ±2-degree range of the mean, and the anterior metaphyseal angle was within ±2 degrees of the mean in 75% (64/85) of the total patients. 44.23% variation (CoV) in posterior slop degrees, 2.73% (CoV) variation in the anterior metaphyseal angle measured by the same researchers. The difference between the percentages of variation was also found to be statistically significant. (z = 15.36, p = 0.000). CONCLUSION: The anterior metaphyseal angle can be utilized to predict the individual posterior slope. Nevertheless, further large-scale, multicentre studies are needed to establish a mean value for the population.

Supracondylar extra-articular femur fracture after cementless unicompartmental knee replacement: A rare complication.

This case report defines an infrequent complication of unicompartmental knee replacement. Periprosthetic supracondylar femoral fracture after total knee replacement is a challenging problem for orthopedic surgeon. To the best of our knowledge, this is the only case describing periprosthetic supracondylar femoral fracture after unicondylar knee replacement.

The initial analysis of pediatric fractures according to the AO/OTA fracture classification and mechanisms of injuries.

BACKGROUND: The epidemiology of pediatric fractures has been changing timely, in a multifactorial fashion. The aim of this study was to put forward a recent 5-year epidemiological analysis of pediatric fractures, according to the current AO/OTA fracture classification, in the current decade of action for road safety. METHODS: A total of 3261 pediatric patients who were diagnosed with at least one fracture related with orthopedics and traumatology in a level-one trauma center were included in this retrospective and epidemiological descriptive study. The patients were grouped according to their ages as follows; <2, 2-5.9, 6-9.9, and 10-17.9. The fractures were examined according to the AO/OTA classification. RESULTS: A total of 3396 fractures were present in 3261 patients. The mean age of the patients was 9.8±4.6 (1-17). The number of patients according to the age groups was as follows; 28 (0.008%), 735 (22.53%), 863 (26.47%), and 1635 (50.99%), respectively. The most frequent three fractures according to the AO/OTA fracture classification were; 23 (radius/ulna distal 22.9%), 13 (humerus distal, 13.3%), and 7 (hand/carpal, 12%). About 68.8% and 31.2% of the patients were treated non-surgically and surgically, respectively. Overall mortality rate was 0.1%. CONCLUSION: To the best of our knowledge, this study represents the first analysis of pediatric fractures according to the AO/OTA classification, over a 5-year period. As a future prospect, further multicentric epidemiological studies are warranted to constitute a sustainable action plan for the prevention of major traumas.

The epidemiology of adult fractures according to the AO/OTA fracture classification.

BACKGROUND: The epidemiology of adult fractures has been changing timely, in a multifactorial fashion. The aim of this study was to put forward a recent 5-year epidemiological analysis of adult fractures, according to the current AO/OTA fracture classification, in the current decade of action for road safety. METHODS: 5324 adult patients who were diagnosed with at least one fracture related with orthopedics and traumatology in a level-one trauma center were included in this retrospective, epidemiological descriptive study. The patients were grouped according to their ages as; 18-35, 36-55, 56-69, and ≥70. The fractures were examined according to the AO/OTA classification. RESULTS: 5865 fractures were present in 5324 patients. The mean age of the patients was 48.6±21.5. The number of patients according to the age groups was as follows; 1947 (36.6%), 1636 (30.7%), 881 (16.5%), and 860 (16.2%), respectively. The most frequent three fractures according to the AO/OTA fracture classification were; 7 (hand 19.6%), 23 (distal forearm, 12.1%), and 8 (foot, 11.8%). About 54.4% and 45.4% of the patients were treated non-surgically and surgically, respectively. About 0.2% of the patients preferred an alternative treatment. Overall mortality rate was 0.4%. CONCLUSION: To the best of our knowledge, this study represents the first analysis of adult fractures according to the AO/OTA classification, over a 5-year period. As a future prospect, further multi-centric epidemiological studies are warranted to constitute a sustainable action plan for the prevention of major traumas.

Improvement of Life After PVCR in Complete Paraplegic Patients with Posttraumatic Severe Kyphosis.

AIM: To determine the effect of posterior vertebral column resection (PVCR) in patients with paraplegia by using the American Spinal Injury Association (ASIA) score and Scoliosis Research Society (SRS)-22 questionnaire. MATERIAL AND METHODS: Twelve patients with posttraumatic paraplegia and severe angular kyphosis ( > 60?) had undergone PVCR between 6-24 months after the trauma for severe pain, persistent vertebral instability and difficulty in adherence to rehabilitation. ASIA scores and SRS-22 questionnaire results obtained in the preoperative and postoperative periods, and the last control were statistically compared to assess the presence of any change. RESULTS: The average age of twelve patients included in this study was 35.6 ± 10.2 (21-51) years. Female/male ratio was 2/10 (20.0%). The mean follow-up duration was 50.3 ± 17.6 (24-86) months. None of the patients had additional changes in neuromonitoring records during surgery. The mean preoperative kyphotic angle of the patients was 66.58° ± 7.1? (60?-82?) which decreased to 7.0? ± 5.4? in the postoperative period (p < 0.05). The mean ASIA score, which was 43.3 ± 5.1 preoperatively, increased to 44.4 ± 4.4 in the postoperative period. The SRS-22 score, which was 2.4 ± 0.3 in the preoperative period, increased to 4.2 ± 0.4 in the early postoperative period. This increase was found to be statistically significant (p < 0.05). The SRS-22 score was 4.1 ± 0.4 at last follow-up and was not statistically different from the early postoperative value (p > 0.05). CONCLUSION: In the light of these data, it can be stated that PVCR is a safe and reliable procedure in paraplegic patients with rigid posttraumatic kyphosis and increases patient satisfaction.

Cadaver versus simulator based arthroscopic training in shoulder surgery

Introduction: There are few studies that compare the cadaver dissections with the medical simulators in means of talent improvement. Therefore, the aim of this study is to find out if using cadaver dissections is still the golden standard for surgical training or using the medical simulators in surgery could replace cadaver dissections. Materials and methods: The study is conducted during the European Orthopaedics & Traumatology Education Platform accredited Shoulder Club International Cadaver Course including a number of 34 orthopedics trainees. The participants were randomly divided into two groups to be trained with the simulator (Group 1) and on cadavers (Group 2), followed by a test performed on shoulder arthroscopy simulator (Virtamed ArthroS, Switzerland). There was no conflict of interest before, during, or after the study. Informed consent was obtained from all individual participants included in the study. Results: Group 2 had statistically significant higher simulation overview procedure time values than Group 1 (p < 0.05), the meaning of which is participants trained with the simulator completed the given tasks in a shorter period of time. Group 2 had statistically significant higher scratching of humerus cartilage values than Group 1 (p < 0.05), which means that participants trained with simulation have less scratching done on the humerus cartilage than the participants trained on a cadaver. Conclusion: To the best of our knowledge, this study is the first one to compare virtual reality (VR) simulators with cadavers for surgical education in an objective manner, while using qualitative and quantitative data. According to this study, it is possible to state that VR simulators are just as effective as cadavers in means of training subjects. As medical education will face a total change all around the world after the COVID-19 pandemic, this study has the potential to be an important guide during and after this period.

Biological augmentation strategies in rotator cuff repair.

Rotator cuff tears (RCT) are a common problem encountered by orthopaedic surgeons. The incidence of re-tears (up to 94%) following surgical repair of RCTs renders the management of RCTs challenging. This higher re-tear rate has been attributed to the failure of healing at the tendon-bone junction. Biological augmentation methods such as growth factors, stem cell therapies, and biomaterials have been developed to promote the healing at the tendon-bone junction. Growth factors and stem cell therapies have been intensively studied in mid to large RCTs. Biomaterials have been generally utilized for large or massive RCTs. However, these newly generated biological augmentation strategies are mostly studied in animal models. The efficacy and safety of the biological augmentation methods in humans need further investigation. In this review, we aimed to highlight the most recent advancements in RCT surgical repair with biological augmentation.

No Decrease in Infection Rate with the Use of Local Vancomycin Powder After Partial Hip Replacement in Elderly Patients with Comorbidities.

Introduction The goal of this study was to evaluate the effects of local intra-wound vancomycin powder (VP) administration to decrease surgical site infections (SSIs), particularly in elderly patients with comorbidities, after having undergone partial hip replacement in the treatment of intertrochanteric (ITF) or femoral neck fractures (FNF). Methods We retrospectively reviewed patients who underwent partial hip replacement in the treatment of ITF or FNF in one year. We divided the patients into two groups. The non vancomycin-treated group received standard systemic prophylaxis only (1 gr cefazolin IV), while the vancomycin-treated group received 1 gr of VP in the surgical wound just before surgical closure in addition to the systemic prophylaxis. We included patients of 64 years or older who also had one or more comorbidities. We compared the post-operative SSI rates between the non vancomycin-treated group and the vancomycin-treated group. Results A total of 93 patients were included in the study. We detected post-operative wound infection in six patients (6.4%). The rate of SSI was found to be 5.7% in the vancomycin-treated group and 6.9% in the non vancomycin-treated group respectively, which showed no statistically significant difference (p:0.498). The incidence of SSI was statistically higher in the patients who had a follow-up in the post-operative intensive care unit than the patients who had not any follow-up in the intensive care unit. Conclusion Local application of VP in the surgical wound was found to be ineffective in reducing the incidence of SSI after partial hip replacement in elderly patients with comorbidities.

DIAGNOSIS AND TREATMENT OF RETAINED WOODEN FOREIGN BODIES IN THE EXTREMITIES USING ULTRASOUND.

OBJECTIVE: This study investigates ultrasonography as an effective tool for localizing and measuring the depth and size of wooden foreign bodies to perform less invasive and easier surgery without the need for any additional radiological techniques. METHODS: Fifteen patients were operated to remove foreign bodies in the extremities in 2016. The side of the affected extremity, the material, size, and location of the foreign body and time of admission after injury were noted, along with CRP, WBC, and erythrocyte sedimentation rate; length of incision, surgery duration, and complications were evaluated. RESULTS: The mean patient age was 39.66 (range: 6 to 68). Of the total, 8 of the foreign bodies were in the plantar surfaces of the feet, 3 were in the cruris, 2 were in the palm of the hand, and 2 were in the fingers. All patients underwent ultrasound evaluation before surgery. The surgeries lasted less than 10 min in 13 (87%) of the cases and from 10 to 20 min in 2 cases. No complications were observed in any of the patients. CONCLUSION: Delayed extraction of foreign bodies can lead to local infections. Ultrasonography can be a reliable option for diagnosing and localizing radiolucent foreign bodies such as wooden objects. Level of Evidence IV; Case series.

OBJETIVO: Neste estudo, procuramos mostrar que a ultra-sonografia é uma ferramenta eficaz para localizar e medir a profundidade e o tamanho dos corpos estranhos em madeira, a fim de realizar uma cirurgia menos invasiva e mais fácil, sem a necessidade de técnicas radiológicas adicionais. MÉTODOS: 15 pacientes foram submetidos à cirurgia para penetração de corpo estranho nas extremidades em 2016. O lado da extremidade afetada, o material, tamanho e localização do corpo estranho e o tempo de admissão após lesão foram observados. CRP, WBC e taxa de sedimentação de eritrócitos também foram observados. O comprimento da incisão, duração da operação e complicações foram avaliados. RESULTADOS: A idade média do paciente foi de 39,66 (intervalo: 6 a 68). No total, oito de todos os corpos estranhos estavam no lado plantar dos pés, três estavam no crúis, dois estavam na palma da mão e dois estavam nos dedos. Todos os pacientes foram submetidos a avaliação ultra-sonográfica antes da cirurgia. A duração da operação foi inferior a 10 minutos em 13 (87%) dos casos e entre 10 a 20 minutos em dois casos. As complicações não foram observadas em todos os pacientes. CONCLUSÃO: A extração retardada de corpos estranhos pode levar a infeções locais. A ultra-sonografia pode ser uma opção confiável para diagnosticar e localizar corpos estranhos radiolúcidos, como objetos de madeira. Nível de evidência IV; Série de casos.

The triangle between the anterior and posterior cruciate ligaments: an arthroscopic anatomy study.

OBJECTIVE: The goal of anterior cruciate ligament (ACL) reconstruction is to place the graft in closest proximity to the native ACL anatomy. This study aims to examine the angular relation between intact anterior and posterior cruciate ligaments (PCL) from an arthroscopic perspective. METHODS: Forty patients (20 male, 20 female) with a mean age of 35.12 (range: 18-40) years that underwent knee arthroscopy for reasons other than ACL rupture were included in the study. Following diagnostic examination and repair of the primary pathology, the triangle between ACL and PCL was seen at different flexion degrees of the knee joint (120, 90, 60, and 30°) through standard anterolateral (AL) and anteromedial (AM) portals. The narrow top angle of the triangle between the long intersecting axes of ACL and PCL was measured using recorded images by 3 blind observers. RESULTS: The average ACL-PCL angle was 61°, (standard deviation±2°) at 90°of knee flexion. The angles were narrower when viewed through the AM portal. The degree of the angles was not affected by age, sex, body mass index (BMI), or the side (right or left) on which the procedure was performed. There was good-to-excellent intra- and interobserver reliability. CONCLUSION: The angular relation between intact ACL and PCL has the potential to provide a better view of the anatomy during arthroscopic ACL surgery. To perform better anatomic reconstructions, it is important to create a 60° angle between the ACL graft and PCL (as viewed through AL portal) at 90°of knee flexion.

Cementless total hip arthroplasty in developmental dysplasia of the hip with end stage osteoarthritis: 2-7 years' clinical results.

Between 2006 and 2011, 102 hips of 78 patients with end-stage osteoarthritis secondary to developmental dysplasia of the hip (DDH) underwent cementless total hip arthroplasty (THA). According to the Crowe's classification, 22 hips (21%) were type 1, 19 hips (18%) were type 2, 22 hips (21%) were type 3 and 39 hips (38%) were type 4 respectively. Functional and clinical analyses were performed by Harris Hip Scores (HHS). There were 73 (71%) excellent or good results according to HHS. The postoperative HHS was significantly lower in patients who underwent femoral shortening (p<0.01). We observed 25 (24.5%) complications in total, 15 (14.7%) of which required revision surgery. The authors concluded that THA for DDH is a safe and a reliable procedure with good clinical outcomes.

Outcomes for revision total knee replacement after unicompartmental knee replacement.

OBJECTIVE: The aim of this retrospective, observational study was to describe the outcomes of total knee replacement (TKR) after failed Oxford phase 3 medial unicompartmental knee replacement (UKR). METHODS: The study included 24 revision TKRs (20 females, 4 males; mean age: 61 years) performed following failed aseptic UKR. Outcomes were assessed using the Knee Society Score (KSS). RESULTS: The most common causes for revision were mobile bearing dislocation and unexplained pain. Mean preoperative KSS was 50.3 (range: 37 to 66) and 82.2 (range: 58 to 97) after TKR. There were 17 excellent, 4 good, 2 fair and 1 poor results. CONCLUSION: The type of UKR performed (cemented versus uncemented) had no effect on TKR success. Revision for failed UKR with TKR appears to be a technically straightforward procedure with satisfactory early clinical results.

Medial femoral condyle fracture after cementless unicompartmental knee replacement: a rare complication.

This case report describes a rare complication of unicompartmental knee arthroplasty. Femoral fracture after TKR is a serious and relatively common problem, but to the best of our knowledge, only one case of femoral condylar fracture after UKA has been reported thus far.

Cemented versus Uncemented Oxford Unicompartmental Knee Arthroplasty: Is There a Difference?

Purpose. The use of uncemented unicompartmental knee prostheses has recently increased. However, few studies on the outcomes of uncemented unicompartmental knee prostheses have been performed. The purpose of this study was to compare the outcomes of cemented and uncemented Oxford unicompartmental knee arthroplasty. Materials and Methods. This retrospective observational study evaluated the clinical and radiological outcomes of 263 medial Oxford unicompartmental prostheses (141 cemented, 122 uncemented) implanted in 235 patients. The mean follow-up was 42 months in the cemented group and 30 months in the uncemented group. Results. At the last follow-up, there were no significant differences in the clinical results or survival rates between the two groups. However, the operation time in the uncemented unicompartmental knee arthroplasty group was shorter than that in the cemented unicompartmental knee arthroplasty group. In addition, the cost of uncemented arthroplasty was greater. Conclusion. Despite the successful midterm results in the uncemented unicompartmental knee arthroplasty group, a longer follow-up period is required to determine the best fixation mode.

[Osteochondritis dissecans occurring in the patella and medial femoral condyle in the same knee]. / Ayni dizde patella ve medial femoral kondilde görülen osteokondritis dissekans.

Osteochondritis dissecans (OCD) is a condition in which a portion of articular cartilage separates from the bone together with the underlying subchondral bone. Its classical localization is the medial femoral condyle. We presented a 14-year-old boy who had OCD lesions in both the medial femoral condyle and patella in the same knee joint. He presented with complaints of pain, swelling, and locking following sports activities. Magnetic resonance imaging showed completely detached loose bodies causing instability. Arthroscopic treatment was performed including in situ fixation of the condylar lesion and debridement of patellar lesions. At six-month follow-up, he had full range of motion of the knee joint, with some pain in the patellar grind test.