Comparative finite element analysis of four different internal fixation implants for Pauwels type III femoral neck fractures in various fracture angles in the sagittal plane.

OBJECTIVES: This study aimed to evaluate the performance of four different fixation techniques for Pauwels type III femoral neck fractures considering the fracture morphology in the sagittal plane. MATERIALS AND METHODS: We constructed three different fracture morphologies in the sagittal plane in Pauwels type III femoral neck fractures: posteriorly angled at 20°, neutral, and anteriorly angled at 20°. We set up four fixation devices, including three cannulated screws (3CS), a dynamic hip screw with an antirotational screw (DHS+CS), a proximal femoral locking plate (PFLP), and three cannulated screws with a medial buttress plate (3CS+MBP). The twelve models were created and analyzed using the finite element analysis. RESULTS: The finite element analysis revealed that 3CS+MBP yields better results in total vertical and rotational displacements, regardless of the fracture angle in the sagittal plane. For the anterior and posterior angled fractures in the sagittal plane, the PFLP was superior to the DHS+CS. However, the DHS+CS exhibited less displacement than the PFLP in the neutral fracture line in the sagittal plane. The 3CS group demonstrated poor mechanical stability for Pauwels type III fractures. CONCLUSION: Regardless of the fracture line in the sagittal plane, the 3CS+MBP showed better biomechanical behaviors than the 3CS, DHS+CS, and PFLP. In addition, in contrast to the DHS+CS, the PFLP displayed less vertical and rotational displacement in the anterior and posterior fracture lines in the sagittal plane.

Treatment of knee osteochondritis dissecans with autologous tendon transplantation: Clinical and radiological results.

BACKGROUND: Defect treatment with tendon autograft in osteochondral lesions has been published in the literature with an experimental study in dogs. To demonstrate that it is possible to treat knee osteochondral lesions with the technique of autologous tendon transplantation. AIM: To evaluate the clinical and radiological results of patients with knee osteochondral lesions who were treated with autologous tendon transplantation. METHODS: Twenty patients (22 knees) with osteochondritis dissecans (OCD) lesions involving the knee were treated with autologous tendon transplantation between 2005-2018. All lesions were International Cartilage Repair Society grade IV. All patients were evaluated clinically at final follow-up with knee injury and osteoarthritis outcome score (KOOS); and radiologically with magnetic resonance observation and cartilage repair tissue (MOCART) and Kellgren-Lawrence (KL) classification. RESULTS: A total of 20 patients (22 knees) with a mean age of 25.5± 6.8 years were included. The average defect size was 4.2 ± 2.1 cm2, and the average defect depth was 0.9 ± 0.4 cm. Total KOOS score was preoperatively 29.4 ± 5.5 and was later found to be 81.5 ± 5.9 after an average of 68.7 ± 37.7 mo follow-up. The mean MOCART score was 56.2 ± 10.7. Preoperatively, all of the patients had KL grades of 0-1; during the follow-up period, 80% of the patients showed no radiological progress of osteoarthritis. Patients with less than 4 cm2 lesion had statistically significantly better overall KOOS than patients whose more than 4 cm2 lesion, particularly in sport and quality of life subscales. CONCLUSION: The autologous tendon transplantation is a single-step, safe, simple, cost-effective method for the treatment of knee OCD with satisfactory clinical and radiological outcomes, particularly in patients with less than 4 cm2 lesion.

Comparison of two surgical methods in the treatment of intra-articular distal radius fractures: Volar locking plate and K-wire augmented bridging external fixator.

BACKGROUND: In this study, we aimed to compare the radiological, clinical and functional results of volar radius locking plate, and K-wire augmented bridging external fixator (BEF) treatments that applied in intra-articular distal radius fractures. METHODS: Between May 2016 and January 2019, 162 patients who met the inclusion criteria of 23-C2 and 23-C3 according to the AO/OTA classification who operated in our clinic were evaluated retrospectively. 78 patients (37 males, 41 females, mean age 49.92) were fixated with K wire augmented BEF and 84 patients (41 males, 43 females, mean age 46.81) were fixated with volar locking plate (VLP). Demographic (age, gender, type of trauma, and follow-up time), radiological (radial inclination, radial height, volar tilt, and fracture healing time), and clinical and functional (range of motion [ROM], grip strength, Quick Dash, Green O'Brien and Mayo scores) data of the patient groups were recorded and compared statistically. RESULTS: There was no significant difference between the patient groups in terms of functional scoring systems. Radiologically, radial inclination, and radial length were significantly better in the volar plate group. In terms of joint ROM, flexion, extension, pronation, and supination movements were significantly better in the VLP group. Sudek atrophy incidence and loss of grip strength were higher in BEF group. Mean time of union was significantly shorter in the BEF group. CONCLUSION: Successful results can be obtained in both treatment methods. However, VLP treatment provides better joint ROM and lower complication rates compared to BEF treatment.

The effect of the angle between fracture line and Kirschner wires on stability in supracondylar humerus fractures treated with Kirschner wire fixation: A finite element analysis.

OBJECTIVES: This study aims to investigate the effects of the angles created by the Kirschner wires (K-wires), which are applied in the percutaneous fixation of supracondylar humerus fractures with cross K-wire, with the fracture line on fracture stabilization. PATIENTS AND METHODS: The study was conducted on distal humerus fracture models. Medial and lateral K-wires were placed in the fracture models. The angle between the fracture line and the K-wire inserted from medial was represented by alpha (α), while the angle between the fracture line and the K-wires inserted from lateral was represented by beta (ß). A combination of various angles (30°, 45°, and 60°) was used in each model, where no two models had the same combination of α and ß, resulting in nine different wire configurations. The simulation program was used to simulate the effects of forces, which were applied on rotation, flexion and extension directions, on these models. We measured and compared the stress on the wires and the displacement of fractures under different force configurations. RESULTS: When the force was applied in the counterclockwise direction, the stresses were 58 megapascal (MPa) on medial K-wire, 24 MPa on lower lateral K-wire, and 45 MPa on upper lateral K-wire in (45°, 45°) wire configuration. When the force was applied in the clockwise direction, the stresses were 57 MPa on medial K-wire, 23 MPa on lower lateral K-wire, and 45 MPa on upper lateral K-wire in (45°, 45°) wire configuration. In all models, the increased α and ß angles were translated into the decreased stress on K-wires at the fracture level and decreased displacement under rotational deforming forces. Despite having generally lower fracture displacement, the increased α and ß angles led to variable changes in the stress on K-wires against flexion and extension forces. CONCLUSION: In supracondylar humerus fractures, increasing the insertion angle of both medial and lateral K-wires augments stabilization and reduces displacement, particularly against rotational deforming forces.

Analysis of Clinical Outcomes in Pediatric Distal Tibia Triplanar Fractures Treated Surgically and Conservatively.

Purpose We aimed to analyze the clinical and functional outcomes of patients who underwent surgery or received conservative treatment to look into the impact of treatment methods on clinical outcomes. Methods A retrospective study was performed on 25 patients with a minimum one-year follow-up. Patients were divided into two groups based on joint and physis displacement measured on preop CT images. Patients with a displacement of > 2 mm underwent surgery, while those with a displacement of < 2 mm received conservative treatment. The clinical results were assessed using the Ankle-Hindfoot Scale developed by the American Orthopedic Foot and Ankle Society (AOFAS) and the Modified Weber Protocol (MWP). Results The sample consisted of 14 patients who underwent surgery and 11 patients who received conservative treatment. The surgical group had a mean follow-up of 36.79±14.43 months, while the conservative group had a mean follow-up of 31.82±13.55 months. The surgical and conservative groups had a postop 1st-year AOFAS score of 96.64±3.54 and 93.64 ± 4.69, respectively. The difference was statistically insignificant (p > 0.05), but the surgical group had higher scores numerically. The surgical and conservative groups had a postop 6th-month AOFAS score of 84.64±1.64 and 80.82±2.85, respectively. The difference was statistically significant (p < 0.05). Conclusion The results of both surgical treatment and conservative treatment are satisfactory. Especially, surgical treatment should not be avoided in patients requiring surgery with a displacement of more than 2 mm and surgeons may consider surgery for better clinical outcomes and earlier rehabilitation in the treatment of triplane fractures.

Is the fracture morphology in the sagittal plane important in determining the ideal placement of the lag screw in intertrochanteric femoral fractures?: Ideal lag screw placement in intertrochanteric fractures in the sagittal plane.

OBJECTIVE: The aim of this study was to determine the ideal placement of the lag screw taking into account the fracture morphology in the sagittal plane. MATERIALS AND METHODS: Three different morphology of fractures were created on the sagittal plane in femur models obtained in 3D CT scanning: posteriorly angled (Type A), transverse (Type B) and anteriorly angled (Type C). The lag screw was applied in each of the three fracture morphology as neutral, anteverted and retroverted in the sagittal plane. The nine models created were transferred to the Ansys Workbench program and analyzes were performed. RESULTS: In Type A fracture, the stress value at the lag screw apex increase as the lag screw placement changes from the anteverted position to the retroverted position. It decreases in the Type B and Type C fractures. As the lag screw placement is changed towards the anteverted position, the stress at the lag screw-nail junction decreases in the Type A fracture and increases in the Type C fracture . There is no significant change in the Type B fracture. As the lag screw placement is changed towards the anteverted position, the stress in the calcar region increases in Type A fractures and decreases in Type C fractures. There is no significant change in type B fractures. CONCLUSION: While the ideal lag screw placement in a type A fracture in the sagittal plane is the retroverted placement, the anteverted placement is ideal placement in type C fractures. Fracture morphology in the sagittal plane should be taken into account in the lag screw placement.

A new proximal femoral nail antirotation design: Is it effective in preventing varus collapse and cut-out?

OBJECTIVES: This study aims to compare the mechanical features of the existing proximal femoral nail antirotation (PFNA) system and the new PFNA system that we designed using three-dimensional (3D) finite element analysis. MATERIALS AND METHODS: This experimental study was conducted between 2019 and 2020. We constructed two femur models with Arbeitsgemeinschaft für Osteosynthesefragen (AO) type A1 fractures using 3D computed tomography scans. The new and standard PFNA designs were inserted into the femur models and subsequently transferred to the program. We investigated the distribution of stress on the tip of the lag screw, the calcar region, lag screw-nail junction, and the additional screw inserted through the greater trochanter (only present in the new PFNA design) using 3D finite element analysis. RESULTS: When the von Mises stress distributions in our models were examined, the maximum stress at the lag screw-nail junction was 18 mpa in the new design PFNA, while it was 20 mpa in the classic PFNA model. The maximum stress at the junction of the additional screw that had greater trochanter inlet with the nail was found as 42.5 mpa. The maximum stress on the calcar region was found to be 10 mpa at the new design PFNA, while it was 13 mpa with 30% increase in the classic PFNA. The stress on the tip of the lag screw was found to be 49 mpa in the classic PFNA design, while in the new design PFNA it was found as 28 mpa with a decrease of more than 40%. CONCLUSION: As per our findings, the new PFNA design leads to reduced stress on the lag screw-nail junction, the calcar region, and the tip of the lag screw.

Is 48 h a critical cut-off point for mortality in geriatric hip fractures?

Background/aim: In this study, our objective was to evaluate the mortality in geriatric hip fracture patients who were operated within 48 h after admission or after the 48thh. Materials and methods: A total of 194 patients who had undergone surgery for hip fracture between 2016 and 2018 were retrospectively evaluated. Patient information was obtained from the hospital's database using the ICD codes 81.52, 82.00­82.09, and 82.10. Radiological examination reports were collected from the patient files. Information on mortality was obtained from the Death Notification System of the Turkish Ministry of Health. First-year mortality rates of patients operated within 48 h (Group 1) and those operated at 48­96 h (Group 2) were compared. Results: The mean duration between admission to the hospital and surgical intervention was 33.90 ± 1.95 h (3­96 h). The mean total hospitalization time was 7.29 ± 1.53 days (2­36 days). Of the patients, 62 (32%) died within one year after the operation. The mean survival times for patients operated ≤48 h or >48 h were 8.47 ± 1.90 and 6.57 ± 2.59 months, respectively (Z = 1.074, P = 0.283). There was no significant correlation between survival time and the time delay before the operation (r = ­0.103, P = 0.153). Additionally, the Cox regression analysis, including age (years), ASA (grade 3 vs. 2), time to operation (h), and days spent in the ICU, demonstrated no significant independent effect of the time to operation on survival (P = 0.200). Conclusion: Although shortening the time to surgery may have some rationale, we did not find any difference in patients operated before 48 h compared to 48­96 h concerning mortality.

Metatarsal Head Restoration With Tendon Autograft in Freiberg's Disease: A Case Report.

Freiberg's disease is a form of osteochondrosis of a metatarsal head that often affects the second metatarsophalangeal joint, and that affects females more often than males. Repetitive microtrauma, osteonecrosis, and stress overload are the main factors in its pathophysiology. Surgical intervention is indicated in advanced cases wherein nonoperative treatment has failed. In this report, we describe the case of a young female who had Freiberg's disease localized to the third metatarsal head bilaterally and who was successfully treated with peroneus longus tendon transplantation.

Predicting postoperative pain with neutrophil/ lymphocyte ratio after arthroscopic rotator cuff repair.

BACKGROUND: Postoperative pain is well known and usually disturbing complication of arthroscopic shoulder surgery. Inflammation plays an important role in the development and progression of postoperative pain. The aim of this study was to evaluate the predictability of postoperative pain through the correlation of neutrophil/lymphocyte ratio (NLR) with inflammation. In addition, the correlation of parameters such as operative time, tear size, age and gender with postoperative pain was evaluated. METHODS: Sixty three patients, who underwent arthroscopic rotator cuff repair, were evaluated in this single-center-based retrospective study. The American Society of Anaesthesiologists I and II risk groups were determined as the inclusion criteria. NLR was calculated using preoperative one day hemogram values in all patients. The amounts of analgesic use and Numerical Rating Scale (NRS) scores at the 12th, 24th and 48th hours and on the 3rd and 7th days were recorded. Multivariate linear regression analysis was used to correlate postoperative NRS scores with multiple independent factors, including preoperative NLR, sex, age, tear size, repair type, operative time, block time, postoperative analgesic intake and length of hospital stay. RESULTS: Sixty three patients with a mean age of 59.4 years (range, 40-72 years) were evaluated. The mean tear size was 2.8 cm (range, 1-5 cm), the mean operative time was 84.1 min (range, 35-135 min), the mean duration of block was 7.6 hours (range, 4-12 hours) and the mean length of hospital stay was 1.7 days (range, 1-3 days). There was no significant correlation between age, sex, tear size, repair type, operative time and postoperative NRS (p > 0.2). The preoperative NLR was found to be a strong predictor of postoperative NRS (p < 0.001, rho = 0,864). There was a correlation between the NLR and mean analgesic intake (p = 0,03). The duration of block was decreased in patients with a NLR above 2, while it was prolonged in patients with a NLR below 2 (p = 0.04, rho = -0,725). CONCLUSION: The preoperative NLR was found to be a strongest factor predicting high acute pain levels after arthroscopic rotator cuff surgery. Likewise, NLR was also predictive of postoperative block time and analgesic consumption.