How reliable are the synovial cell count and blood parameters in the diagnosis of septic arthritis?

OBJECTIVES: This study aims to investigate the reliability of the joint fluid cell count and blood parameters compared to the culture results in the diagnosis of septic arthritis (SA). PATIENTS AND METHODS: A total of 192 patients (112 males, 80 females, mean age: 60.3±19.2 years; range, 18 to 98 years) who presented with SA between January 2018 and July 2022 were evaluated retrospectively. The recorded joint fluid cell count, complete blood count (CBC), white blood cell (WBC) count, serum erythrocyte sedimentation rate (ESR) and serum C-reactive protein (CRP) and culture results were analyzed comparatively according to SA diagnosis. RESULTS: The most commonly involved joint was the knee joint (82.3%), which was affected in 158 patients. Thirty-six (18.8%) of the patients who underwent joint aspiration had positive culture result. The cultures were positive in 10 (35.7%) of 28 patients with synovial WBC value greater than 50,000/mm3, while 26 (15.9%) of 164 patients with a synovial WBC value less than 50,000/mm3 had positive culture results (p=0.013). CONCLUSION: Patients with SA may present variable blood and synovial parameters. Making decision based on the commonly used synovial WBC count cut-off value of 50,000/mm3 may lead to misdiagnosis. To avoid misdiagnosis or delay in treatment, it is of utmost importance not to exclude the diagnosis acutely, and suspicion of SA should remain even with unlikely values.

Volumetric Analysis of Subacromial Space After Superior Capsular Reconstruction for Irreparable Rotator Cuff Tears.

Purpose: Subacromial volume measurement on magnetic resonance images is relatively new. It has been shown that decreased subacromial volume increases after surgical repair of full-thickness rotator cuff tears. There is no study examining subacromial volume changes after superior capsular reconstruction (SCR). The purpose of this study was to compare subacromial volume changes on magnetic resonance images (MRI) after superior capsular reconstruction performed for primary irreparable rotator cuff tears. Methods: Patients who underwent an SCR procedure between 2017 and 2019 with a minimum 2-year postoperative follow-up were included in this retrospective study. Subacromial volume was measured on MRI using software. The preoperative and postoperative acromiohumeral distance, Constant Scores, graft thickness, and Hamada grades of the patients were evaluated. Results: A total of 18 patients with a mean age of 59.7 years (range: 49-74 years) underwent an SCR for massive irreparable cuff tear. The mean preoperative subacromial volume was 3.54 ± 0.39 cm3 (range 2.88-4.36 cm3), which increased to 4.46 ± 0.39 cm3 (range 3.75-5.32 cm3) postoperatively (p = < 0.001). The increase in subacromial volume and acromiohumeral distance did not correlate with Constant scores and graft thickness. We observed a significantly higher subacromial volume increase among Hamada grade 1 patients, compared to those with Hamada grade 2 (p = 0.011). Conclusions: We observed that subacromial volume significantly increased after superior capsular reconstruction. However, the increase in subacromial volume did not correlate with clinical scores, acromiohumeral distance changes, or graft thickness.Level of evidence: Level III - Retrospective Cohort Study.

Investigation of the effect of ghrelin on bone fracture healing in rats.

Ghrelin is known to have effects on proliferation and differentiation of osteoblasts and improvement of bone mineral density in rats. However, no experimental research on ghrelin's effects on fracture healing has been reported. In this context, the effect of ghrelin on the union of femoral shaft fractures was examined in this study by evaluating whether ghrelin will directly contribute to fracture healing. Forty male Wistar-Albino rats were divided into two groups as control and experimental (ghrelin treated) and standard closed shaft fractures were created in the left femurs of all rats. Daily ghrelin injections were applied to the experimental groups and equal numbers of rats were killed after 14 and 28 days following fracture formation. Tissue samples were examined with radiological, biomechanical, biochemical and histological analyses. Densitometry study showed that bone mineral density was improved after 28 days of ghrelin treatment compared to control. On histological examination, at the end of the 14 and 28 days of recovery, significant union was observed in the ghrelin-treated group. The ghrelin-treated group had higher breaking strength and stiffness at the end of 28 days of recovery. Biochemically, ALP levels were found to be higher in the ghrelin-treated group at the end of 28 days of recovery. Results showed that ghrelin directly contributes to fracture healing and it is promising to consider the effect of ghrelin on fracture healing in human studies with pharmacological applications.

S-allylcysteine inhibits chondrocyte inflammation to reduce human osteoarthritis via targeting RAGE, TLR4, JNK, and Nrf2 signaling: comparison with colchicine.

The discovery of new pharmacological agents is needed to control the progression of osteoarthritis (OA), characterized by joint cartilage damage. Human OA chondrocyte (OAC) cultures were either applied to S-allylcysteine (SAC), a sulfur-containing amino acid derivative, or colchicine, an ancient anti-inflammatory therapeutic, for 24 h. SAC or colchicine did not change viability at 1 nM-10 µM but inhibited p-JNK/pan-JNK. While SAC seems to be more effective, both agents inhibited reactive oxygen species (ROS), 3-nitrotyrosine (3-NT), lipid hydroperoxides (LPO), advanced lipoxidation end-products (ALEs as 4-hydroxy-2-nonenal, HNE), advanced glycation end-products (AGEs), and increased glutathione peroxidase (GPx) and type-II-collagen (COL2). IL-1ß, IL-6, and osteopontin (OPN) were more strongly inhibited by SAC than by colchicine. In contrast, TNF-α was inhibited only by SAC, and COX2 was only inhibited by colchicine. Casp-1/ICE, GM-CSF, receptor for advanced glycation end-products (RAGE), and toll-like receptors (TLR4) were inhibited by both agents, but bone morphogenetic protein 7 (BMP7) was partially inhibited by SAC and induced by colchicine. Nuclear factor erythroid 2-related factor 2 (Nrf2) was induced by SAC; in contrast, it was inhibited by colchicine. Although they exert opposite effects on TNF-α, COX2, BMP7, and Nrf2, SAC and colchicine exhibit anti-osteoarthritic properties in OAC by modulating redox-sensitive inflammatory signaling.

TLR4, RAGE, and p-JNK/JNK mediated inflammatory aggression in osteoathritic human chondrocytes are counteracted by redox-sensitive phenolic olive compounds: Comparison with ibuprofen.

Osteoarthritic chondrocytes show an over-activity of inflammatory catabolic mediators, and olive products have attracted attention because they were discovered to have some benefits on osteoarthritis patients. We investigated the mechanisms of action of olive leaf polyphenolic compounds in osteoarthritic chondrocytes (OACs) using a standardized leaf extract, ZeyEX, and its main phenolic component, oleuropein, also compared with anti-inflammatory drug ibuprofen. OACs, isolated from joint-cartilages of Grade 4 OA patients, were found to express COMP and MMP-9 throughout their culture period. ZeyEX, oleuropein, and ibuprofen increased cell viability at concentrations of 1-100 nM, did not change at 500 nM-50 µM, but inhibited at ≥100 µM. The adherence profile of OACs increased with 1 µM of ibuprofen or ZeyEX and 10 nM-1 µM oleuropein. Although the markers for oxidative and nitrosative stresses (ROS and 3-NT) generally inhibited by three agents, the inhibitory effect of ZeyEX on 3-NT emerged dramatically (1 nM-10 µM). Lipid-hydroperoxides and HNE-adducts were also inhibited by each agent, but AGE-adducts unchanged by oleuropein while reduced by ZeyEX and ibuprofen. Inflammatory biomarkers, IL-1ß, IL-6, Casp-1/ICE, and TNF-α, were inhibited by three agents, however osteopontin and GM-CSF by only ZeyEX and ibuprofen. A decreased COMP, TLR4, and RAGE expression levels were observed by three agents, but only the effects of ZeyEX was concentration-dependent. In particular, ZeyEX and oleuropein improved COL2, inhibited p-JNK/JNK, and increased GPx. COX2 was only inhibited by ibuprofen. The results indicate that polyphenolic-olive compounds counteract redox-sensitive inflammatory aggressions in osteoarthritic chondrocytes that may stop the progression of pathology and allow regeneration.

Lower extremity alignment due to patellofemoral syndrome and dynamic postural balance.

STUDY DESIGN: This study is a prospective study. AIM: Lower extremity malalignment is an important etiologic factor in patellofemoral pain syndrome (PFPS). We hypothesized that lower limb malalignment may affect dynamic balance and physical function. This prospective study was conducted to investigate the relationship between the lower limb alignment and the dynamic balance and physical function in patients with PFPS. METHODS: The study included 62 individuals with unilateral PFPS. Pain severity was assessed by the numerical pain scale and the pain duration was recorded. Lower extremity bone alignment was evaluated by the lateral distal femoral angle (LDFA) and the medial proximal tibia angle. Dynamic postural balance was assessed by the star excursion balance test. The functional status of the patients was evaluated by the 30-second chair stand test. RESULTS: The mean duration of the pain was 24.2 ± 31.5 months and the mean pain severity was 8.1 ± 1.4. Although there was a significant difference found between the affected and unaffected LDFA values of lower extremities (p < 0.05), there was no difference found with regard to the dynamic balance values of the lower extremities (p > 0.05). However, significant changes of posterolateral balance were identified at a painful side without causing a postural dynamic imbalance (p < 0.05). CONCLUSION: In our study, we found a valgus deformity as a deterioration in the lower limb alignment of patients with PFPS which may cause a deterioration of posterolateral balance only. However, no change in postural dynamic balance was observed in the comparison of affected side and unaffected side. Dynamic postural balance has been influenced by many kinematic changes related to lower extremities including pelvis, hip, and ankle. Thus, reciprocal mechanisms in the anatomical structures may compensate the postural balance dynamically.

The Role of Surgical Closure Position in Total Knee Arthroplasty: Flexion versus Extension-A Randomized Prospective Study.

We aimed to investigate the effect of the knee position during the surgical closure on isokinetic muscle strength, clinical score, and range of motion in total knee arthroplasty. Seventy-five eligible patients were enrolled in the study and randomly divided into two groups; wound closure was performed with the knee flexed at 90° in group 1 and knee extended in group 2. All the surgeries were performed by the same surgeon and by the same prosthesis type. All the patients received the same rehabilitation program postoperatively. The primary outcomes were the knee flexion degrees and the American Knee Society Score values at preoperative and postoperative 6 weeks, 3, and 6 months. The secondary outcome was the isokinetic muscle strength measurements of both knees before the surgery and after 6 months. There were no significant differences in the American Knee Society Scores and knee flexion degrees between the flexion and extension groups. However, a significant decrease was found in the extensor muscle strength in the extension group after 6 months of the surgery. The findings of our study are that the closing of the knee in flexion or extension does not affect the postoperative knee flexion degrees and scores in total knee arthroplasty. However, quadriceps strength recovers early if the knee closure is performed in flexion position.

The Evaluation of Exogenous Melatonin Administration in Supraspinatus Overuse Tendinopathy in an Experimental Rat Model.

BACKGROUND: Increased oxidative stress and inflammation play a critical role in the etiopathogenesis of chronic tendinopathy. Melatonin is an endogenous molecule that exhibits antioxidant and anti-inflammatory activity. The aim of this study was to evaluate the biochemical and histopathological effects of exogenous melatonin administrations in supraspinatus overuse tendinopathy. METHODS: Fifty rats were divided into the following four groups: cage activity, melatonin treatment, corticosteriod therapy, and control. Melatonin (10 mg/kg, intraperitoneal; twice a day) and triamcinolone (0.3 mg/kg, subacromial; weekly) were administered to the treatment groups after the overuse period. Biochemical and histopathological evaluations were performed on serum samples and biopsies obtained from rats. Plasma inducible nitric oxide synthase (iNOS), vascular endothelial growth factor (VEGF), total antioxidant status (TAS), total oxidant status (TOS), and oxidative stress index (OSI) levels were evaluated biochemically. RESULTS: The TAS, TOS, OSI, iNOS, and VEGF values were significantly lower than the pre-treatment levels in rats receiving exogenous melatonin treatment (3 or 6 weeks) (p<0.05). TOS, iNOS, VEGF, and OSI values after 3 weeks of triamcinolone administration, and TOS, VEGF, and OSI levels after 6 weeks of triamcinolone application, were significantly lower than the pre-treatment levels (p<0.05). CONCLUSIONS: Exogenous melatonin application in overuse tendinopathy reduces oxidative stress and inflammation. Melatonin might be an alternative potential molecule to corticosteroids in the treatment of chronic tendinopathy.

Subacromial space volume in patients with rotator cuff tear: The effect of surgical repair.

OBJECTIVE: The aim of this study was to evaluate the effect of the rotator cuff tear repair on subacromial space volume. METHODS: We retrospectively identified 21 eligible patients (5 males and 16 females; mean age: 56.4 (range; 46-71) years) who had shoulder arthroscopy for unilateral full-thickness small to medium rotator cuff tear and normal controlateral shoulder joint. The mean follow-up time was 16.1 (range; 12-25) months. Preoperative and postoperative 1 year bilateral shoulder MRIs and Constant scores were reviewed. Subacromial volume was calculated by using Osirix software. Pre-, postoperative and healthy side (contralateral control group) subacromial volumes were recorded. Paired sample and t-tests were used to compare the pre- and postoperative groups. Independent sample t-tests were used to compare the healthy and pre- and postoperative groups. The correlation between the changes in the subacromial volume and the shoulder Constant score were analyzed using Pearson correlation analyses. RESULTS: The mean subacromial volume of the preoperative group was 2.95 cm3 (range; 1.53-4.23) and the postoperative group was 3.59 cm3 (range; 2.12-4.84). The volume increase was statistically significant (p < 0.05). The mean subacromial volume of the control group was 3.93 cm3 (range; 2.77-5.03), and the difference between the preoperative group and the control group was statistically significant. There was no significant difference found between the postoperative group and the control group (p = 0.156). There was no significant correlation found between the volume and the constant score changes (r = 0.170, p = 0.515). CONCLUSION: The subacromial space volume significantly decreases in full-thickness rotator cuff tears smaller than 3 cm and the surgical repair increases the subacromial volume significantly. LEVEL OF EVIDENCE: Level IV; Diagnostic Study.

Acetabular components with or without screws in total hip arthroplasty.

AIM: To compare the operation time, blood loss, and early outcomes of acetabular components with and without the screw. METHODS: Thirty patients who underwent cementless acetabular component with or without screw and whose follow-up exceeded one year period in total hip arthroplasty were evaluated. A posterior approach was used in all surgical procedures by one experienced surgeon. Demographic data, operation time, intra- and postoperative blood loss volume, follow-up clinical score, cup migration, and osteolysis were recorded. The Kolmogorov-Smirnov test was performed for testing the normality of study data. Mann-Whitney U test was used to analyze the inter-group differences. A P-value of ≤ 0.05 was considered statistically significant. RESULTS: Acetabular components were used in 16 (53.3%) patients with screw and 14 (46.7%) without screw. After one year of follow-up, an osteolytic lesion of 3 mm was found in only one patient in the screw group. No cup migration was encountered. Intra-group mean Harris hip score significantly increased, but there was no significant inter-group difference. While the mean operation time of the screw group was 121.8 min (range; 95-140), it was 102.7 min (range; 80-120) in the no-screw group, and this difference was statistically significant (P = 0.002). The mean intraoperative/postoperative, and total blood loss were 556.6 mL (range: 350-800)/423.3 mL (range: 250-600), and 983.3 mL (range: 600-1350), respectively in the screw group; and 527 mL (range: 400-700)/456 mL (range: 230-600), and 983 mL (range: 630-1250), respectively in the no-screw group. The blood loss difference between the two groups was not significant. In the screw group, the operation time was 19.1 min longer than the no-screw group, and this difference was statistically significant. CONCLUSION: Acetabular components with or without screw have similar results, but the use of screw increases the operation time significantly, while not changing the blood loss volume.

A Radiographic Dye Method for Intraoperative Evaluation of Syndesmotic Injuries.

BACKGROUND: The Chertsey test has been recently defined as an intraoperative test for the detection of the syndesmotic injuries by the application of intra-articular contrast. However, no study has investigated the reliability and comparative analysis of the Chertsey test. The purpose of this study was to explore the diagnostic accuracy of the Chertsey test in predicting syndesmosis instability of the injured ankle, with correlation to preoperative computed tomography (CT) findings. METHODS: A total of 39 patients who were operated on due to the unilateral ankle fracture and had no complaint on the contralateral ankle joint were included in the study. An intraoperative Chertsey test was performed on all ankle fractures and bilateral ankle CT was obtained preoperatively. Ankles were classified as Chertsey +, Chertsey -, and contralateral control group. The morphology categorization, width, and volume of the syndesmotic region were measured on axial images of the CT. Mann-Whitney U test was used to compare the data. Intraobserver and interobserver agreements were accessed by calculating the intraclass correlation coefficient (ICC) for radiologic parameters and the Chertsey test. RESULTS: The Chertsey test was positive in 13 (33.3%) of 39 ankle fractures. Patients with a positive Chertsey test showed a significant increase in syndesmotic width and volume compared with Chertsey - and control group. However, there was no significant difference between Chertsey - and the control group. All the ICC values were excellent for both radiologic measurements and test. CONCLUSION: The Chertsey test is a reliable and useful test that can be used intraoperatively in the diagnosis of syndesmotic injuries. LEVEL OF EVIDENCE: III, comparative series.

Use of the smartphone for end vertebra selection in scoliosis.

OBJECTIVES: The aim of our study was to develop a smartphone-aided end vertebra selection method and to investigate its effectiveness in Cobb angle measurement. METHODS: Twenty-nine adolescent idiopathic scoliosis patients' pre-operative posteroanterior scoliosis radiographs were used for end vertebra selection and Cobb angle measurement by standard method and smartphone-aided method. Measurements were performed by 7 examiners. The intraclass correlation coefficient was used to analyze selection and measurement reliability. Summary statistics of variance calculations were used to provide 95% prediction limits for the error in Cobb angle measurements. A paired 2-tailed t test was used to analyze end vertebra selection differences. RESULTS: Mean absolute Cobb angle difference was 3.6° for the manual method and 1.9° for the smartphone-aided method. Both intraobserver and interobserver reliability were found excellent in manual and smartphone set for Cobb angle measurement. Both intraobserver and interobserver reliability were found excellent in manual and smartphone set for end vertebra selection. But reliability values of manual set were lower than smartphone. Two observers selected significantly different end vertebra in their repeated selections for manual method. CONCLUSION: Smartphone-aided method for end vertebra selection and Cobb angle measurement showed excellent reliability. We can expect a reduction in measurement error rates with the widespread use of this method in clinical practice. LEVEL OF EVIDENCE: Level III, Diagnostic study.

Sagittal plane tilting deformity of the patellofemoral joint: a new concept in patients with chondromalacia patella.

PURPOSE: The aims of this study were to evaluate sagittal plane alignment in patients with chondromalacia patella via magnetic resonance imaging (MRI), analyse the relationships between the location of the patellar cartilaginous lesions and sagittal alignment and finally investigate the relationships between the sagittal plane malalignment and patellofemoral loadings using by finite element analysis. METHODS: Fifty-one patients who were diagnosed with isolated modified Outerbridge grade 3-4 patellar chondromalacia based on MRI evaluation and 51 control subjects were evaluated. Chondromalacia patella patients were divided into three subgroups according to the chondral lesion location as superior, middle and inferior. The patella-patellar tendon angle (P-PT) was used for evaluation of sagittal alignment of patellofemoral joint. Each subgroup was compared with control group by using P-PT angle. To investigate the biomechanical effects of sagittal plane malpositioning on patellofemoral joint, bone models were created at 30°, 60° and 90° knee flexion by using mean P-PT angles, which obtained from patients with chondromalacia patellae and control subjects. The total loading and contact area values of the patellofemoral joints were investigated by finite element analysis. RESULTS: The mean age of all participants was 52.9 ± 8.2 years. The mean P-PT angle was significantly lower in chondromalacia group (142.1° ± 3.6°) compared to control group (144.5° ± 5.3°) (p = 0.008). Chondral lesions were located in superior, middle and inferior zones in 16, 20 and 15 patients, respectively. The mean P-PT angles in patients with superior (141.8 ± 2.7) and inferior subgroups (139.2 ± 2.3) were significantly lower than the values in the control group (p < 0.05). The contact area values were detected higher in models with chondromalacia than in the control models at the same flexion degrees. There were increased loadings at 30° and 90° flexions in the sagittal patellar tilt models. CONCLUSION: This study revealed that sagittal plain malpositioning of the patellofemoral joint might be related to chondromalacia, especially in the presence of lesions in the upper and lower part of the patella. This condition leads to supraphysiological loadings on the patellofemoral joint. Sagittal patellar tilt should be considered in the evaluation and management of patellar cartilage defects. Taking sagittal plane malalignment into consideration in patellofemoral joint evaluation will enable us to design new physical and surgical modalities. LEVEL OF EVIDENCE: IV.

Gartland Type 3 Supracondylar Humeral Fractures in Children: Which Open Reduction Approach Should Be Used After Failed Closed Reduction?

OBJECTIVES: For displaced supracondylar humeral fractures in children, in the event of closed reduction failure, anatomic reduction is achieved via open reduction techniques; however, there are no confirmative reports among the published open reduction approaches that deliver the best functional and cosmetic results. Here, we compared long-term functional and cosmetic results of different surgical approaches. DESIGN: Retrospective cohort study. SETTING: Ankara Education and Research Hospital/Turkey. Secondary care hospital and trauma center. PATIENTS/PARTICIPANTS: We evaluated 70 surgically treated Gartland type 3 supracondylar humeral fractures. Patients, with detailed history record, were divided into 5 groups with respect to surgery methods. INTERVENTION: All patients were treated surgically using closed reduction and percutaneous pinning or 4 different open reduction approaches and percutaneous pinning. MAIN OUTCOME MEASURES: Flynn cosmetic and functional score results were compared between surgical groups. RESULTS: Posterior open reduction and triceps transection groups showed worst results, whereas medial and lateral open reduction groups showed good to excellent results similar to closed reduction group. CONCLUSION: Medial and lateral approaches demonstrated better functional results than posterior and triceps transection approaches. Posterior approaches lead to restrictions in extension and poor functional results. In the posterior approach, transecting triceps from olecranon does not benefit from fracture reduction but results in loss of triceps strength and should be avoided. In failed closed reduction, medial and lateral open reduction approaches lead to similar cosmetic outcomes and functional results that are only slightly worse compared with those in closed reduction. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Is There Any Difference Between The Biomechanical Strengths Of The Current Fixation Techniques For Comminuted Distal Patellar Fractures? (Comparison Of Distal Patella Fracture Fixation Techniques).

In this biomechanical study, the strength of five different fixation techniques -anterior tension band wiring with K-wires, separate vertical wiring, headless compression screws with anterior tension band wiring, cannulated screws with tension band wiring and memory shape patellar fixator- for distal patellar fractures were compared. Forty calf knees were used for the biomechanical testing. Each specimen was pre-loaded with 10 N at 1 N/s. The distraction forces were applied consistently with the velocity of 5 mm/s. The ultimate load (N) and displacement (mm) values were recorded. The headless compression screw with anterior tension band wiring (656.9±167.9 N) and the cannulated screws with anterior tension band wiring (642.6±166.0 N) obtained significantly higher ultimate loading values compared to the other fixation methods (p<0.05). Fixation via cannulated screws with anterior tension band wiring techniques are more stabile than the patellar shape memory fixator and anterior K wire fixation.

Evaluation of Reduction Accuracy of Suture-Button and Screw Fixation Techniques for Syndesmotic Injuries.

BACKGROUND: Among the most important predictors of functional results of treatment of syndesmotic injuries is the accurate restoration of the syndesmotic space. The purpose of this study was to investigate the reduction performance of screw fixation and suture-button techniques using images obtained from computed tomography (CT) scans. METHODS: Patients at or below 65 years who were treated with screw or suture-button fixation for syndesmotic injuries accompanying ankle fractures between January 2012 and March 2015 were retrospectively reviewed in our regional trauma unit. A total of 52 patients were included in the present study. Fixation was performed with syndesmotic screws in 26 patients and suture-button fixation in 26 patients. The patients were divided into 2 groups according to the fixation methods. Postoperative CT scans were used for radiologic evaluation. Four parameters (anteroposterior reduction, rotational reduction, the cross-sectional syndesmotic area, and the distal tibiofibular volumes) were taken into consideration for the radiologic assessment. Functional evaluation of patients was done using the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale at the final follow-up. The mean follow-up period was 16.7 ± 11.0 months, and the mean age was 44.1 ± 13.2. RESULTS: There was a statistically significant decrease in the degree of fibular rotation (P = .03) and an increase in the upper syndesmotic area (P = .006) compared with the contralateral limb in the screw fixation group. In the suture-button fixation group, there was a statistically significant increase in the lower syndesmotic area (P = .02) and distal tibiofibular volumes (P = .04) compared with the contralateral limbs. The mean AOFAS scores were 88.4 ± 9.2 and 86.1 ± 14.0 in the suture-button fixation and screw fixation group, respectively. There was no statistically significant difference in the functional ankle joint scores between the groups. CONCLUSION: Although the functional outcomes were similar, the restoration of the fibular rotation in the treatment of syndesmotic injuries by screw fixation was troublesome and the volume of the distal tibiofibular space increased with the suture-button fixation technique. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Effects of body mass index, infrapatellar fat pad volume and age on patellar cartilage defect.

The aim of this study was to evaluate the associations between patellar cartilage defects and body mass index (BMI), infrapatellar fat pad (IPFP) volume and age. 100 patients who met the inclusion criteria and were aged 18 to 60, were evaluated retrospectively. For detecting and measuring patellar cartilage defects, axial sequences were used and sagittal sequences were used to evaluate IPFP volumes. In total, 40 patients had patellar cartilage defects. In this group, age and BMI were higher in both sexes when compared with the controls (p<0.05). The IPFP volume was lower in the group with the patellar cartilage defect when compared with the control group (p<0.05). The IPFP volume was statistically significantly lower in women (p<0.05). Patellar cartilage defect was found to be related to age and BMI. In women, the decrease in IPFP volume seems to be one of the causative factors for patellar cartilage defect.

Effect of surgical closing in total knee arthroplasty at flexion or extension: a prospective, randomized study.

PURPOSE: The aim of this study was to evaluate the effect of knee position during wound closure (flexed vs. extended) in total knee arthroplasty on knee strength and function, as determined by knee society scores and isokinetic testing of extensor and flexor muscle groups. METHODS: In a prospective, randomized, double-blind trial, 29 patients were divided in two groups: for Group 1 patients, surgical closing was performed with the knee extended, and for Group 2 patients, the knee flexed at 90°. All the patients were treated with the same anaesthesia method, surgical team, surgical technique, prosthesis type, and rehabilitation process. American Knee Society Score values and knee flexion degrees were recorded. Isokinetic muscle strength measurements of both knees in flexion and extension were taken using 60° and 180°/s angular velocity. The peak torque and total work values, isokinetic muscle strength differences, and total work difference values were calculated for surgically repaired and healthy knees. RESULTS: No significant difference in the mean American Knee Society Score values and knee flexion degrees was observed between the two groups. However, using isokinetic evaluation, a significant difference was found in the isokinetic muscle strength differences and total work difference of the flexor muscle between the two groups when patients were tested at 180°/s. Less loss of strength was detected in the isokinetic muscle strength differences of the flexor muscle in Group 2 (-4.2%) than in Group 1 (-23.1%). CONCLUSION: For patients undergoing total knee arthroplasty, post-operative flexor muscle strength is improved if the knee is flexed during wound closure. LEVEL OF EVIDENCE: II.

Arthroscopic treatment of a case with concomitant subacromial and subdeltoid synovial chondromatosis and labrum tear.

Synovial chondromatosis is a disease that seldomly seen in shoulder joint and is related to benign synovial proliferation and synchronous chondral tissue formation within the joint cavity. Patients suffer from progressive restriction of range of motion and shoulder pain. Extra-articular involvement is an extremely rare condition. Degenerative osteoarthritis, joint subluxation, and bursitis are common complications in untreated patients. Open or arthroscopic surgery is suitable while there is no consensus related to superiority of different approaches. We presented an arthroscopic treatment of a male patient, 48 years old with labrum tear and synovial chondromatosis localized in subacromial and subdeltoid region. Advantages of arthroscopic surgery in the presence of intra- and extra-articular combined pathologies are also discussed.