Clinical Results of Decortication with Bone Grafting Method versus Extracorporeal Shock Wave Treatment in Long-Bone Pseudoarthrosis.

BACKGROUND Despite advanced treatment methods, the treatment of pseudoarthrosis still poses a significant challenge for orthopedists. In this study, we aimed to assess the clinical results of decortication and bone grafting and extracorporeal shock wave treatment (ESWT) in long-bone pseudoarthrosis. MATERIAL AND METHODS Between 2007 and 2015, 68 fractures of 66 patients treated for long-bone pseudoarthrosis were evaluated retrospectively. ESWT was used in 36 extremities and decortication and iliac bone grafting was used in 32. The treatment results of these patients were evaluated and compared with rates in the literature. RESULTS The mean patient age was 43.9 years (range, 21-69). The mean interval between the occurrence of the fracture and treatment with bone grafting or ESWT was 8.6 months and the mean interval between the procedure and achievement of union was 6.9 months. The patients were followed up for a mean period of 25.2 months. After the mean follow-up period, bone union had occurred in all 32 patients (100%) in the decortication and bone grafting group and in 28 (78%) of the 36 patients in the ESWT group (P=0.023). CONCLUSIONS This study shows that extracorporeal shock wave treatment should be considered the first option in treatment of pseudoarthrosis as it is a non-invasive method and also provides good rates of union. In patients that do not heal with ESWT, decortication and bone grafting remains the criterion standard therapy.

Comparison of two coracoid process transfer techniques on stress shielding using three-dimensional finite-element model.

BACKGROUND: We created patient-based 3D finite-element (FE) models that simulate the congruent-arc Latarjet (CAL) and traditional Latarjet (TL) procedures and then compared their stress distribution patterns with different arm positions and glenoid defects. METHODS: The computed tomography data of 10 adult patients (9 men and 1 woman, ages: 18-50 years) were used to develop the 3D FE glenohumeral joint models. Twenty-five and 35% bony defects were created on the anterior glenoid rim, and the coracoid process was transferred flush with the glenoid by the traditional and congruent-arc techniques using two half-threaded screws. A load was applied to the greater tuberosity toward the center of the glenoid, and a tensile force (20 N) was applied to the coracoid tip along the direction of the conjoint tendon. The distribution patterns of the von Mises stress in the traditional and congruent-arc Latarjet techniques were compared. RESULTS: The mean von Mises on the graft was significantly greater for the TL technique than for the CAL. While the von Mises stress was greater in the distal medial part of the graft in the TL models, a higher stress concentration was observed in the distal lateral edge of the coracoid graft in the CAL models. The proximal medial part of the graft exhibited significantly lower von Mises stress than the distal medial part when compared according to technique, defect size, and arm position. Increasing the glenoid defect from 25 to 35% resulted in a significant increase in stress on the lateral side of the graft in both models. CONCLUSION: The stress distribution patterns and stress magnitude of the coracoid grafts differed according to the procedure. Due to placing less stress on the proximal-medial part of the graft, the CAL technique may lead to insufficient stimulation for bone formation at the graft-glenoid interface, resulting in a higher incidence of graft osteolysis. Clinical relevance The CAL technique may lead to a higher incidence of graft osteolysis. LEVEL OF EVIDENCE: Basic Science Study; Computer Modeling.

Association of the Interfacet Angle and the Lunate Facet Inclination Angle With Kienböck Disease.

PURPOSE: The etiology of Kienböck disease remains unclear, although mechanical, vascular, and metabolic risk factors have been suggested. We aimed to investigate the association of the angle between the curvatures of the distal radius and the development of Kienböck disease. METHODS: The lunate facet inclination (LFI), scaphoid facet inclination, and interfacet angle (IFA) values were measured using posteroanterior plain radiographs of 82 patients diagnosed with Kienböck disease. The results were compared with normative angular reference values published based on an analysis of 400 wrists of Caucasian patients aged between 20 and 45 years. The posteroanterior radiographs were divided into 3 categories: negative, neutral, and positive based on ulnar variance, and the relationship between ulnar variance and facet angles was evaluated. RESULTS: The IFA value was significantly higher than the normative angular reference value in the patients with Kienböck disease. Conversely, the LFI values were significantly lower in the Kienböck patient group. There were no statistically significant differences in the IFA and LFI values among the ulnar variance groups. CONCLUSIONS: Measuring IFA and LFI allows the evaluation of the bifacet curvature of the distal radius articular surface in the coronal plane. Steep IFA and shallow LFI are associated with Kienböck disease. Increased IFA may lead to abnormal load transmission to the intermediate column, which might eventually lead to increased stress on the lunate. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Outcome of free gracilis muscle transfer for the restoration of elbow flexion in traumatic brachial plexus palsy.

OBJECTIVES: The aim of this study was to evaluate the functional outcomes of patients with free gracilis muscle transfer (FGMT) for the restoration of elbow flexion. PATIENTS AND METHODS: Between January 2012 and January 2019, a total of 16 patients (13 males, 3 females; mean age: 27.3±11.7 years; range: 18 to 53 years) who underwent FGMF to achieve elbow flexion after traumatic brachial plexus palsy (TBPP) were retrospectively analyzed. Data including demographic and clinical characteristics of the patients, etiology, affected side, injury level, accompanying injuries, time between injury and surgery, follow-up time, complications, whether nerve reconstruction and artery repair were performed previously, and details of the procedure were recorded. The outcome measures were elbow range of motion in degrees, muscle strength, and Disabilities of the Arm, Shoulder and Hand (DASH) and Short Form-36 (SF-36) scores. RESULTS: The mean follow-up was 30±11.5 (range, 24 to 42) months. Two patients had C5-C8 injuries, two patients had C6-T1 injuries, and all other patients had injuries to the C5-T1 roots. Muscle strength was M3/M4 in 11 (68.8%) patients, M2 in two (12.5%) patients, and M0 in one (6.2%) patient. The median active range of motion of the elbow joint in patients with successful results (M3 and above) was measured as 75 (range, 30 to 100) degrees. A statistically significant improvement was observed in the pre- and postoperative DASH scores and in some SF-36 subscale scores of patients with successful results. CONCLUSION: Free gracilis muscle flap is a reliable option in the restoration of elbow flexion in patients with TBPP. Although there is an improvement in functional results, disability, and quality of life, there may be no change in patients' mental status and pain.

Propeller flap: Orthoplastic approach for coverage of distal leg and ankle defects.

BACKGROUND: Covering soft tissue defects of the distal one-third of the leg and the Achilles tendon region and is a challenging problem for an orthopedic surgeon. With recent advancements in the anatomical knowledge of perforating vessels, perforator-pedicled propeller flaps have become increasingly popular in recent decades. We aimed to evaluate the clinical outcomes of our patients whose soft tissue defects in the distal leg were reconstructed with propeller flaps and assessed association of complications with age, gender, flap size and arc of rotation. METHODS: Patients that had a reconstruction with a propeller flap at the ankle from 2013 to 2019 were retrospectively reviewed. The main indications for the propeller flap were small- and medium-sized soft tissue defects of the distal lower limb. 20 propeller flaps were applied to 19 patients (14 male, 5 female) for various lower extremity defects. RESULTS: The mean follow-up duration was 2 years (range, 6 months to 6 years). The average flap size was 82 cm2 (range, 48-125 cm2). The flap was rotated 180 degrees in nine patients The source of the perforator vessel was the tibialis posterior artery in 14 cases, the peroneal artery in 4 cases, both the tibialis posterior and peroneal arteries in 1 case. Four complications (20 %) occured postoperatively. Two patients developed partial necrosis at the tip of the flap, and two patients developed superficial epidermolysis. No correlations were found between complications and flap size and the arc of rotation. CONCLUSIONS: The propeller flap is a reliable option for reconstruction of small to moderate defects in the lower extremity with good clinical results and minimal donor-site morbidity. It is applicable for orthopedic surgeons who do not have microsurgical experience or an available microscope in the operating room.

Comparison of Turkish and international trends in carpal tunnel surgery.

OBJECTIVES: This study aims to analyze the nationwide trends in carpal tunnel surgery by surgeons practicing in Turkey according to experience in years, training received (plastic surgery or orthopedics), and working location (Turkey or abroad) by slightly modifying Munns' survey. MATERIALS AND METHODS: A printed and online survey consisting of 11 questions was sent to Turkish and international surgeons. The surgeon's province of practice, years in practice, type of education received as a resident, preferred operation room, preferred surgical approach, type of anesthesia used, use of postoperative orthosis and therapy were assessed in the survey. RESULTS: The survey was completed by 198 surgeons (a 25% response rate). The majority of surgeons practicing in Turkey (87%) and 67% of surgeons practicing abroad demanded electromyography (EMG) and nerve conduction studies. Sixty- one percent of respondents from Turkey and 76% of respondents practicing abroad did not administer antibiotics preoperatively. While the most common anesthetic technique used by international surgeons was subcutaneous local anesthesia (42%), Turkish surgeons preferred wrist block (18%). Surgeons practicing in Turkey with fewer than five years of experience were more likely to administer antibiotics preoperatively, use EMG/nerve conduction studies, utilize a mini-open approach and apply an orthosis postoperatively (p<0.05). CONCLUSION: There are comparable differences between Turkish and international surgeons regarding pre- and postoperative management of carpal tunnel surgery. Province of practice, years in practice, and type of education received as a resident have influence over the management of carpal tunnel syndrome.

Trephine biopsy versus conventional open surgical technique for bone graft harvesting from the olecranon: A retrospective comparison of perioperative outcomes.

OBJECTIVE: This study aimed to compare the perioperative clinical outcomes of trephine biopsy (TB) with the conventional open surgical method (COSM) in bone graft harvesting from the olecranon. METHODS: In this retrospective study, 130 patients who underwent bone graft harvesting from the olecranon using either TB or COSM were included. Patients were then divided into two groups: the COSM group (48 patients; 36 men and 12 women; mean age=32 years; age range=18-52) and the TB group (82 patients; 61 men and 21 women; mean age=34 years; age range=20-62). The mean follow-up was 30 months (range=17-57) in the COSM group and 26.8 months (range=6-48 months) in the TB groups. The two groups were compared in terms of pain intensity, operating time, complication rate, elbow range of motion, and the scar sensitivity of the graft donor site. Pain intensity was measured using the visual analogous scale (VAS) on postoperative days 1 and 15. Other outcome measures were evaluated at the final follow-up. RESULTS: In the TB group, the mean VAS score was 4±1.62 on postoperative day 1 and 1.6±0.76 on postoperative day 15. In the COSM group, the mean VAS score was 7.2±1.38 on postoperative day 1 and 3.1±1.34 on postoperative day 15. The early VAS scores were significantly higher in the COSM group than in the TB group (p<0.05). The mean operating time was 7±1.99 minutes in the TB group and 20±4.51 minutes in the COSM group. Hematoma occurred in one patient from each group, with an incidence of 2.1% in the COSM group and 1.2% in the TB group. There was no significant difference between the two groups regarding elbow range of motion at final follow-up p>0.05). No patient in the TB group showed sensitivity of the scar region, while scar sensitivity occurred in 3 of 48 patients (0.6%) in the COSM group. CONCLUSION: Compared with COSM, TB seems to be a safe technique with similar complication rates. TB can provide shorter operating time, less postoperative pain, and smaller and less sensitive scar compared with COSM. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Comparison of surgical trends in zone 2 flexor tendon repair between Turkish and international surgeons.

OBJECTIVES: The aim of this study was to evaluate Turkish trends in zone 2 flexor repair with regards to surgical technique, suture materials, anesthesia and post-operative rehabilitation and compare this with international surgeons by modifying Gibson's survey. METHODS: A printed and online survey consisting of 19 questions modified from Gibson's survey was sent to 590 Turkish and international surgeons. The surgeon's years in practice, province of practice, residency type, number of zone 2 flexor tendon repairs done in a year, preferred surgical technique, suture material, complications and postoperative protocols were asked to the respondents. RESULTS: A total of 194 surgeons completed the survey (a 25% response rate). Of those who completed the survey, 91 were international (mostly from far eastern countries) and 103 were Turkish surgeons. Years in practice and educational background had influence on the decision-making. There were differences between the Turkish and international surgeons in the core and epitendinous suture thickness preference and flexor tendon sheath repair. There was a statistically significant relationship between the province of practice and the use of WALANT (Wide awake local anesthesia no tourniquet) (p < 0.05). While the majority of respondents who preferred postoperative early passive motion protocol were from Turkey (61.5%), the majority of respondents who preferred early active motion protocol were practicing abroad (73.9%). CONCLUSION: Despite some variations the surgeons involved in this study follow to a large extent the current literature.

Effectiveness of etofenamate for treatment of knee osteoarthritis: a randomized controlled trial.

The intramuscular application of etofenamate in the treatment of knee osteoarthritis was not observed in the existing English language literature. The objectives of this study were to compare the efficacy of etofenamate versus hyaluronic acid (HA) in reducing joint pain and functional improvement for mild to moderate knee osteoarthritis. The patients were randomly divided into etofenamate (n=29) and HA (n=30) groups. Intramuscular etofenamate injection was administered as a series of seven intramuscular injections at intervals of 1 day. Intra-articular HA injection was administered as a series of three intra-articular injections at intervals of 1 week. Clinical evaluation was made before the first injection and again both 6 and 12 months after the last injection. The evaluation consisted of patient-assessed pain on a visual analog scale (VAS) and on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Statistical significance was found for the etofenamate group when comparing preinjection with 12 months postinjection VAS scores (P<0.05). Statistical significance was also found for the HA group when comparing preinjection with 12 months postinjection VAS and WOMAC scores (P<0.05). However, there was no significant difference between the etofenamate and HA groups in terms of VAS or WOMAC scores measured at 12 months after injection (P>0.05). Results from this study indicated that, etofenamate treatment was not significantly more effective than HA treatment. However, both methods were effective and successful in treating knee osteoarthritis.

An Alternative Surgical Method for Treatment of Osteoid Osteoma.

BACKGROUND An osteoid osteoma is a benign bone tumor that tends to be <1 cm in size. The tumor is characterized by night-time pain that may be relieved by aspirin or other non-steroidal anti-inflammatory drugs. Osteoid osteoma can be treated with various conservative and surgical methods, but these have some risks and difficulties. The purpose of the present study was to present an alternative treatment method for osteoid osteoma and the results we obtained. MATERIAL AND METHODS In the period from 2010 to 2014, 10 patients with osteoid osteoma underwent nidus excision by using a safe alternative method in an operating room (OR) with no computed tomography (CT). The localization of the tumor was determined by use of a CT-guided Kirschner wire in the radiology unit, then, in the OR the surgical intervention was performed without removing the Kirschner wire. RESULTS Following the alternative intervention, all the patients were completely relieved of pain. In the follow-up, no recurrence or complication occurred. CONCLUSIONS The presented alternative method for treating osteoid osteoma is an efficient and practical procedure for surgeons working in clinics that lack specialized equipment.

Ewing's Sarcoma of the Finger.

Ewing's sarcoma is a mesenchymal cell tumor usually seen in long bones but very rarely seen in the bones of a finger. Swelling and pain are the most common complaints of the affected finger. In radiological imaging, it may be seen as permeative bone destruction accompanied by a soft tissue component or an expansile bone lesion. A 27-year-old right-hand dominant female patient presented with a swelling on the proximal phalanx of her right 3(rd) finger that had existed for 3 years. However, the mass started to gradually increase in size and the pain worsened over a period of 5 weeks. The mass was excised under regional intravenous anesthesia and Ewing's sarcoma was confirmed following a histopathological evaluation. No local recurrence or metastasis was detected 1 year after surgery. Since Ewing's sarcoma is rarely seen in the finger, we present this case with its radiological and clinical findings.

Removal of metallic foreign bodies embedded in soft tissues by stereotaxic approach.

BACKGROUND: A trial fibrillation (AF) is the most common cardiac arrhythmia and increases the risk of stroke and death. Patients with hypertensive have an increased risk of developing atrial fibrillation. RDW (Red blood cell distribution width) levels are elevated in cardiovascular disorders including heart failure, stable coronary disease, acute coronary syndrome, slow coronary flow and stroke. OBJECTIVE: To investigate the relation between RDW and AF in patients with hypertensive. METHOD: We retrospectively examined 126 consecutive hypertensive patients (63 hypertensive patients with AF and 63 hypertensive patients without AF matched with age and sex. RESULTS: The mean age of the study population was 71,09± 8,50 (af group) and 70,97±8,24 (non-af group) years. RDW level was different among patients with atrial fibrillation and without atrial fibrillation.(15,13±1,58 and 14,05±1,15 p<001). Logistic regression analysis showed that RDW and left atrial dimension were only independently risk factory associated with atrial fibrillation. (Rdw odds ratio:1,846 CI; 1,221-2,793 p<0,05). Roc curve analyses were applied to determine the cut-off point. Cut-off point was at 14,195 and Sensitive, specificity was %71,4, %56 respectively. CONCLUSION: RDW levels were higher in hypertensive patients with atrial fibrillation. An increased RDW level in the patient with hypertension may alert physician on developing or presence of atrial fibrillation.