Treatment of Relapsed and Neglected Pes Equinovarus with Binary Arthrodesis and Hexapodal Spider Frame.

PURPOSE: The aim of this study was to assess the clinical and radiological outcomes of patients with recurrent or neglected pes equinovarus (PEV), who underwent talonavicular or calcaneocuboid arthrodesis with a hexapod spider frame. METHODS: The study included 18 patients; a total of 25 feet were treated with dual arthrodesis and a hexapod spider frame. The International Club Foot Study Group (ICFSG) scoring system and visual analog scale (VAS) were used to assess preoperative status and postoperative outcomes. All functional, morphological and radiologic evaluations during the follow-up were done as described by Kling et al. RESULTS: Patients were followed up for an average of 24.1 ± 11.8 months. The mean age of our cohort was 8.84 ± 2.83 years. The mean duration of correction was 3 weeks and the mean duration treatment length was 15.3 ± 1.9 weeks. Postoperative assessment revealed eight excellent, 13 good, and four poor outcomes, according to the ICFSG scoring system. There was a significant difference between preoperative and postoperative ICFSG scores, 12 feet showed an excellent outcome, 12 feet had good outcomes, and one foot was rated as a failure in the final assessment, based on the Kling criteria. There was also a significant difference between preoperative and postoperative VAS scores. CONCLUSION: Dual arthrodesis plus a hexapod spider frame is a valuable option for patients with recurrent or neglected PEV. It can be offered safely to avoid secondary recurrences and potential complications in cases of rigid feet as well as challenging cases that are resistant to soft tissue manipulation.

Diffusion tensor imaging of the median nerve healing. Preliminary results.

AIMS: This study aimed to examine the correlation between DTI, clinical assessment, and electromyography results in patients who underwent primary median nerve repair. METHODS: Ten patients who underwent primary repair of the complete median nerve transection were included. Study assessments were performed on both the traumatized and non-traumatized extremities and patients were followed up for a minimum duration of 11 months. Clinical assessments, (Tinnel test, static 2-point discrimination test, motor and quality of life assessments), electromyography and DTI were performed. RESULTS: None of the clinical or electromyographic parameters correlated significantly with any of the diffusion tensor imaging parameters, i.e. fractional anisotropy (FA) or apparent diffusion coefficient (ADC) (p>0.05 for all). In addition, The Disabilities of the Arm, Shoulder and Hand (DASH) scores did not correlate with either FA (r=0.55, p=0.098) or ADC (r=0.40, p=0.260) values. However, Tinnel positive cases (n=3) had lower relative FA when compared to Tinnel negative cases (n=7) (-0.11±0.19 vs. 0.05±0.04, p=0.033). CONCLUSION: Our findings do not support the presence of relations between DTI parameters and electromyographic or most of the clinical parameters. Further MRI studies with larger numbers of patients with complete transection of the median nerve using the novel imaging parameters are warranted. KEY WORDS: Diffusion Tensor Imaging (DTI), Electromyography (EMG), Median nerve, Nerve injury, Nerve repair.

Medium-term outcomes of mosaicplasty versus arthroscopic microfracture with or without platelet-rich plasma in the treatment of osteochondral lesions of the talus.

PURPOSE: This study aimed to compare medium-term functional effects of three different treatment modalities in patients with osteochondral lesions of the talus (OLT). METHODS: Fifty-four patients undergoing arthroscopic surgery for osteochondral lesion of the talus were included in this study. Patients were assigned to one of the three treatment groups: microfracture surgery (n = 19), microfracture surgery plus platelet-rich plasma (PRP) (n = 22), and mosaicplasty (n = 13). Function was assessed using the American Orthopedic Foot and Ankle Society (AOFAS) scoring system and VAS scores for pain, before and after surgery. In addition, the Foot and Ankle Ability Measure (FAAM) tests for pain and 15-min walking were done at follow-up visits. RESULTS: The median duration of follow-up was 42 months (range 12-84 months). All groups showed significant improvements in AOFAS and VAS pain scores at the last follow-up visit, when compared to baseline. The groups did not differ with regard to change in baseline AOFAS score; however, improvement in VAS pain scores was significantly better in the mosaicplasty group when compared to the microfracture group (change from baseline, -5.8 ± 1.0 vs. -3.2 ± 2.9, p = 0.018). CONCLUSIONS: All the three treatment modalities resulted in good medium-term functional results. However, mosaicplasty procedure seems to be a promising option and it might be preferred particularly in patients where pain control is important. LEVEL OF EVIDENCE: II.

Synovial chondromatosis caused mechanical snapping elbow: a case report.

Synovial chondromatosis is a rare and benign proliferative disorder of the synovial membrane in joints and bursae. Herein, we present the case of a 34-year-old male with synovial chondromatosis that caused limitation in the elbow joint in terms of mechanical function.

Surgical excision of peripheral nerve schwannomas: analysis of 11 patients.

OBJECTIVE: Benign schwannomas are the most common tumour of the peripheral nerves. Symptomatic schwannomas are treated by surgical excision, but new neurological deficits may develop. We performed a retrospective review of cases of schwannomas in the extremities and reviewed the relevant literature. METHODS: We retrospectively reviewed the demographic characteristics of 11 patients with schwannomas treated at our institution. We also reviewed the clinical characteristics and postoperative results of these cases, determined the possible risk factors influencing the development of complications and compared the risk factors with those reported in the literature. RESULTS: There were five males and six females with a mean age of 37.6 (range: 17-62) years. The mean postoperative follow-up was 54.6 (range: 26-88) months. Three tumours were located in the forearm and the rest were localized in the lower extremity. No recurrences were observed during the follow-up period. New motor and sensory deficits were observed in only one patient. CONCLUSION: Schwannomas in the extremities can be excised with acceptable risk of neurological deficits. Meticulous dissection is required during surgery.

The effects of human amniotic fluid and different bone grafts on vertebral fusion in an experimental rat model.

OBJECTIVE: The high risk of nonunion represents a challenge in vertebral surgery, thus stimulating new strategies to improve fusion rates. We investigated the effect of 2 different bone grafts and amniotic fluid application on radiologically and histologically evaluated vertebral fusion in an experimental rat model. MATERIALS AND METHODS: Forty-eight 24-week-old Sprague Dawley rats were included and assigned into 1 of 4 groups: allograft group, allograft plus human amniotic fluid group, demineralized bone matrix (DBM) group, or DBM plus human amniotic fluid group. After decortication and L4-L6 spinal fusion, study treatments were applied. Fusion in each rat was examined radiologically and histologically 8 weeks after the intervention. RESULTS: The group that received only allograft had better radiologic scores (median = 3.5; range = 3-4) when compared with the group that received only DBM (median = 2; range = 1-4) (P = 0.002); however, histologic scores did not differ. When amniotic fluid was added to the grafting, allograft-based treatments performed better than DBM-based treatments both on radiologic (median = 4; range = 3-4 vs median = 3; range = 3-4; P = 0.003) and histologic (median = 7; range = 6-7 vs median = 5; range = 3-6; P < 0.001) evaluation. Addition of amniotic fluid did not result in better outcomes in the rats that received DBM-based treatments but based on histologic evaluation, rats that received allograft-based treatments benefited from this application. CONCLUSIONS: Amniotic fluid seems to have an enhancing effect on posterior spinal fusion, particularly when combined with allograft.

Clinical outcomes of platelet rich plasma (PRP) as an adjunct to microfracture surgery in osteochondral lesions of the talus.

PURPOSE: To compare the effect of arthroscopic microfracture surgery alone or in combination with platelet rich plasma (PRP) on functional outcomes in osteochondral lesions of the talus. METHODS: A total of 35 patients were included in the study. Control subjects (n = 16) received treatment with microfracture surgery alone, while the remaining patients (PRP group, n = 19) were also given PRP. After an average follow-up of 16.2 months (range 12-24 months), patients were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system, Foot and Ankle Ability Measure (FAAM), and the visual analogue scale (VAS) for pain. RESULTS: At baseline, AOFAS and FAAM scores were similar in the two groups, whereas pain scores (VAS) were higher in those who were assigned to combined treatment. Despite the latter finding, the combined treatment with PRP resulted in better outcomes in terms of functional scores [AOFAS, 89.2 ± 3.9 vs. 71.0 ± 10.2, (p = 0.001); FAAM overall pain domain, 1.0 (1.0-2.0) vs. 2.5 (1.0-4.0), (p = 0.04); FAAM 15-min walking domain, 1.0 (1.0-2.0) vs. 2.0 (1.0-4.0) (p = 0.001)]; and pain-related scores [VAS, 2.2 ± 0.8 vs. 3.8 ± 1.2, (p = 0.001)] as compared to arthroscopic microfracture surgery alone. CONCLUSIONS: PRP as an adjunct to arthroscopic microfracture surgery for the treatment of osteochondral lesions of the talus resulted in improved functional score status in the medium-term. Further studies to determine the long-term efficacy of this approach were warranted. LEVEL OF EVIDENCE: II.

Comparison of arthroscopic, radioactive and combined synovectomy in the treatment of chronic non-specific knee synovitis.

OBJECTIVE: To compare the outcomes of arthroscopic, radioactive and combined synovectomies in patients with chronic non-specific recurrent synovitis who did not respond to conservative therapy. SUBJECTS AND METHODS: Twenty-nine patients enrolled between 2007 and 2011 were divided into 3 groups: group 1 was treated with arthroscopy, group 2 received a radioactive drug and group 3 received a combined (radioactive and arthroscopic) synovectomy. Treatment efficacy was evaluated by comparing pre- and post-operative Lysholm knee scores (LKS), night pain, resting pain, activity pain and effusions using visual analogue scales (VAS). Patient satisfaction was assessed using the visual analogue patient satisfaction scale (VAPSS). RESULTS: The mean age of the study participants was 41.5 ± 5.2 years (range 14-76), and the mean follow-up period was 33.6 ± 3.2 months (range 17-78). Before treatment, the mean LKS was 41.4 ± 3.4 in group 1, 39.6 ± 3.3 in group 2 and 37.1 ± 4.6 in group 3. After treatment, the corresponding mean LKS were 77.7 ± 2.1, 81.6 ± 2.8 and 91.3 ± 2.7 in groups 1, 2 and 3, respectively; the increase was statistically significant (p < 0.05). The VAS scores before and after treatment decreased significantly (p < 0.05). The mean VAPSS score, a measure of patient satisfaction, was 5.1 ± 1.7, 5.8 ± 1.5 and 7.4 ± 1.8 in groups 1, 2 and 3, respectively, and the difference between groups 1 and 2 was not statistically significant, while that between group 3 and the other two groups was significant (p < 0.05). CONCLUSION: This study showed that the three methods used in individuals with chronic non-specific recurrent synovitis were effective; however, arthroscopic synovectomy in combination with radioactive synovectomy was more effective than the other methods and superior in terms of patient satisfaction.

Comparison of simultaneous bilateral with unilateral total knee arthroplasty.

OBJECTIVE: The aim of this study was to compare simultaneous bilateral total knee arthroplasty (BTKA) and unilateral total knee arthroplasty (UTKA) in terms of morbidity, clinical and radiological findings and quality of life. METHODS: The study included 48 simultaneous BTKAs (46 females, 2 males; mean age: 64.00 ± 8.31 years) and 53 UTKAs (46 females, 7 males; mean age: 64.40 ± 7.45 years) performed between November 2007 and June 2012. Groups were compared with respect to comorbidity, complications, blood transfusion, hospital stay, clinical and radiological (American Knee Society Score) findings and quality of life (SF-36). RESULTS: Three patients in the BTKA group and 1 in the UTKA group required intensive care admission due to pulmonary embolism; 2 cases occurred within the first postoperative 30 days. One BTKA patient died in the early postoperative period and 1 patient from the BTKA and 1 from the UTKA group died within 1 year. Hospital stay, perioperative blood transfusion parameters and mortality rates were significantly different in favor of UTKA and revision operation rates in favor of BTKA (p<0.05). All patients had improved knee and function scores and SF-36 scores. However, there was no significant difference between the groups (p>0.05). CONCLUSION: Simultaneous BTKA should be considered in selected patients under 70 years of age with good compliance and no comorbid disease.

Mid-term results of the elastic intramedullary nailing in paediatric long bone shaft fractures: a prospective study of 102 cases.

The aim of this study was to evaluate the mid-term results of a large series of paediatric patients with long bone shaft fractures who were treated with elastic intramedullary nailing. Between November 2009 and November 2010, 108 long bone shaft fractures in 102 patients were treated with elastic intramedullary nails. The number of nails used, admission time, nail diameter/medullary canal diameter ratio of the nontraumatized extremity, weeks until radiological consolidation, weeks until full weight bearing for the femur and tibia shaft fractures, weeks until the nails were removed, number of radiographs from the diagnosis time to the removal time of nail(s), clinical complications and radiological results were recorded; the union rate, time to union, nonunion, delayed union, malrotation, malalignment, follow-up time and functional outcomes (Flynn outcome scoring) were also recorded. The mean follow-up time was 22.2 (14-30) months. The mean age of the patients was 9.6 (6-15) years for all cases. The mean nail removal time for all cases was 19.2 (17-29) weeks. Eighteen patients developed complications: six had insufficient reductions; two had refractures; four developed a deep infection; one had delayed union that needed revision; two had lower extremity length discrepancies of more than 15 mm; and three had skin impingements. The mean admission time was 19 (6-32) h; the mean number of radiographs from the diagnosis time to the removal time of nail(s) was 14 (8-20) for each fracture. All patients showed excellent or satisfactory results according to Flynn's criteria. The mean time to full weight bearing for the femur and tibia shaft fractures was 62.4 (52-88) days. A nail diameter/medullary canal diameter ratio of over 0.4 showed good results; short union time, less lower extremity length discrepancy and less malalignment were recorded. When patients were informed about possible complications as well as the advantages, almost all chose the operative approach. According to our experience and opinion, elastic intramedullary nailing is the best choice for diaphyseal fractures in children with skeletal immaturity compared with other surgical choices such as osteosynthesis with a plate.

The effects of locally applied simvastatin on an experimental mouse femur nonunion model.

OBJECTIVE: The aim of this study was to assess the effects of locally applied simvastatin on femur nonunions in a mouse model. METHODS: The study included 32 male Wistar albino mice randomly allocated to one of four groups: two control groups (control-4 week [C4w] and control-8 week (C8w)] and two treatment groups (simvastatin-4 week [S4w] and simvastatin-8 week [S8w]). The control groups received dimethylsulfoxide locally injected at a dose of 10 mg/kg/day after surgical intervention for 1 week. Treatment groups received a liquefied form of simvastatin locally to the osteotomy field by injection at a dose of 10 mg/kg/day, starting from the first postoperative day for 1 week. The C4w and S4w groups were sacrificed 4 weeks and the C8w and S8w groups 8 weeks after the end of local treatment. Before sacrifice, intracardiac blood samples were retrieved for biochemical analysis and radiographies were taken. The right femurs of mice were then removed for histopathological evaluation. RESULTS: There were significant differences between the control and treatment groups when evaluated radiologically. Significantly higher levels of bone-specific alkaline phosphatase and osteocalcin values were found in the treatment groups than in the controls (p<0.05). CONCLUSION: According to biochemical, radiological and histopathological results, local application of simvastatin appears to produce beneficial effects on the mouse femur nonunion model.

Intrapelvic pin migration after Salter innominate osteotomy and laparoscopic removal: a case report.

Although there are many methods for the treatment of developmental dysplasia of the hip, Salter innominate osteotomy is a surgical technique presently used successfully worldwide. However, several complications can be found after Salter innominate osteotomy. Kirschner (K) wire migration into the pelvic cavity is not a common occurrence and is also rarely reported in the literature. Here, we report the case of a patient who was admitted to the emergency department of our hospital with acute abdominal pain because of K wire migration into the pelvis. We recommend bending the proximal end of the K wires or using threaded K wires to prevent this complication.

The treatment of eosinophilic granuloma of the humerus with nonvascularized fibular graft and elastic nail.

Eosinophilic granuloma is most common in children. In this paper we describe two children with a history of local swelling and pain in the humeral area who showed pathological fracture of the humerus. Needle biopsies confirmed the diagnosis of eosinophilic granuloma. Surgical procedures were performed in both patients. Both patients showed total remission after wide resection combined with segmental nonvascularized fibular graft and elastic nail. Both patients are currently free of disease after 4-year follow-up. There are several treatment modalities in eosinophilic granulomas such as radiotherapy, chemotherapy, local or systemic steroids, curettage, bone grafting and internal fixation. Although good results have been reported with nonsurgical treatment, surgery is a more effective treatment option in selected cases. In this paper we describe two children with massive solitary eosinophilic granuloma of the humerus who were successfully treated with segment resection and fibular bloc graft.

Congenital total absence of the quadriceps muscle and patella: a case report with computed tomography scan and three-dimensional reconstructions.

In this study, we present three-dimensional computed tomography (CT) scan image findings of a case with congenital total absence of the quadriceps muscle and patella and partial absence of the sartorius muscle, which caused fixed flexion contracture of the knee joint. Physical examination, radiography, three-dimensional CT scan, and chromosome analysis of the patient were done. On physical examination, the knee joint was at 85 degree fixed flexion contracture. Radiographic views demonstrated soft tissue defects around left femur. Chromosome analysis was normal. CT scan showed total absence of the quadriceps femoris muscle and patella. Congenital absence of the extensor mechanism and patella are very rare anomalies. This case differed from other patellar aplasia or dysplasia syndromes with the presence of fixed flexion knee contracture and aplasia of the extensor mechanism.

Is There an Association Between Synovial CD30+ T Lymphocyte Count and Chondral Lesion Depth?

BACKGROUND: Exact role of the inflammation in osteoarthritis is still unclear, but it is thought to originate from synovitis due to micro-crystals or breakdown products of the cartilage. OBJECTIVE: To determine the effect of CD30+ T lymphocytes on the development of osteoarthritis by comparing the lesion depth and synovial CD30+ count in patients with chondral lesions undergoing knee joint arthroscopy. DESIGN: A total of 79 patients with chondral lesions detected during arthroscopy were categorized in 4 different groups based on chondral lesion classification. CD30+ lymphocyte counts were calculated using flow cytometry on synovial fluid samples obtained at the time of initial entrance into the joint and compared between the groups. In addition, biopsy samples obtained from the suprapatellar bursa were stained for histologic examination to identify existence of CD30+ lymphocytes in the synovium. RESULTS: Although there were no significant differences between the first 3 groups in terms of synovial fluid CD30+ lymphocyte counts, patients in Group IV had significantly higher counts (6.2 8 [2.48] vs 2.51 [1.84], 2.97 [2.40], and 3.80 [2.07], respectively; P < 0.05). Except for a single patient with a Grade III chondral lesion, there were no cases of CD30 positivity in synovial tissue. Also there was a correlation between CD30 levels and chondral lesion depth when controlled for age. CONCLUSIONS: Our results indicate higher CD30+ lymphocyte counts in patients with modified Outerbridge Grade IV chondral lesions than in other groups. The origin of the CD30+ lymphocytes may not be the synovial tissue per se. Thus, it was hypothesized that the injured chondral tissues and the associated subchondral structures might have been the source of CD30+ lymphocytes with a possible influence on the development of osteoarthritis.

Fondaparinux versus nadroparin for prevention of venous thromboembolism after elective hip and knee arthroplasty.

OBJECTIVE: To evaluate the efficacy and safety of fondaparinux compared with nadroparin for prevention of venous thromboembolism after arthroplasty. PATIENTS AND METHODS: One hundred fifteen patients were randomized into 2 treatment groups. Patients were given fondaparinux in Group I and nadroparin in Group II. Measurements were performed on Days 1, 5, and 21. The wound area was assessed with a subjective visual analog scale. RESULTS: The blood counts, clinical biochemical tests, and coagulation tests (ie, thrombin time, partial thromboplastin time, activated partial thromboplastin time, fibrinogen, prothrombin time-International Normalized Ratio, and antithrombin III activity) did not show statistically significant differences between Group I and Group II. In both study groups, anti-factor Xa activities increased significantly on the fifth and 21st day. The scores of the subjective visual analog scale showed significance on Day 21. CONCLUSIONS: Our results confirm the safety and efficacy of both fondaparinux and nadroparin for prophylaxis after major orthopedic surgery.

Royal jelly and bee pollen decrease bone loss due to osteoporosis in an oophorectomized rat model.

OBJECTIVES: In this study, we aimed to investigate whether royal jelly and bee pollen reduce the bone loss due to osteoporosis in oophorectomized rat model. MATERIALS AND METHODS: Thirty-two female Sprague-Dawley mature rats at six-month-old, weighing 180-260 g were used in the study. The rats were divided into four groups: Sham-operation group, only oophorectomy group, oophorectomy in combination with royal jelly group, and oophorectomy and bee pollen group. The rats were sacrified within 12 weeks following surgery. Bone mineral density (BMD) was measured and blood samples were collected for biochemical analysis before sacrification. Following sacrification, uterine weights were measured and tissue samples were taken to determine bone calcium and phosphate level with imaging through scanning electron microscope. RESULTS: The uterine weights of the rats were found higher in Sham-operation group than the other groups. The difference among the groups was statistically significant (p=0.001). Total body BMD results were similar in all groups and there was not statistically significant difference (p=0.19). The lumbar spine and proximal femur BMD results were statistically significantly higher in the royal jelly and bee pollen groups, compared to only oophorectomy group (p=0.001). Bone tissue calcium and phosphate levels were higher in royal jelly and bee pollen groups. CONCLUSION: Royal jelly and bee pollen decrease the bone loss due to osteoporosis in oophorectomized rat model. These results may contribute to the clinical practice.

An unusual initial presentation of Proteus syndrome: macrosyndactyly.

Proteus syndrome is a complex disorder characterized by a wide variety of deformities including macrodactyly. In the present report, we present a case with complex macrosyndactyly in his hand. The patient was surgically treated. However, he admitted with lymphangiomas on his body during the follow-up period, leading to the diagnosis of Proteus syndrome. This article discusses the differential diagnosis of Proteus syndrome and the treatment methods used for macrodactyly along with the presentation of the case.

Effects of propolis on fracture healing: an experimental study.

Propolis is a substance of honeybee origin with known antioxidant effects. The purpose of this study was to examine the effects of propolis on fracture healing and the antioxidant system in an experimental setting. Thirty-two rats that underwent experimental femur fracture and then fixation were randomly allocated in one of four groups: two control groups (Control-3w and Control-6w) and two treatment groups (Propolis-3w and Propolis-6w). Treatment groups received propolis until killing (at 3 or 6 weeks). X-ray, histological, bone mineral density measurement findings and endogenous antioxidant levels were examined. The bone mineral density was higher, radiological and histological evaluation scores were better, and superoxide dismutase, total glutathione and myeloperoxidase levels were lower among the rats that received oral propolis treatment compared with the controls. In addition, bone mineral density and histological assessment scores showed time-dependent improvement in the treatment group. In conclusion, the findings of this study suggest that propolis has some time-dependent beneficial effects on fracture healing.