Evaluation of posterior tibial slope relationship with common knee pathologies in pediatric and adolescent age groups in the Turkish population.

Anterior cruciate ligament rupture (ACLR), tibial eminence fracture (TEF), and Osgood-Schlatter disease (OSD) have been linked to a steep posterior tibial slope (PTS) in children and adolescents. This study aims to examine and compare these associations. 418 patients aged 8-18, 237 males and 181 females with knee pain between 2010 and 2019 were included and the patients belonged to the Turkish population. They consisted of ACLR (n = 47), TEF (n = 22), OSD (n = 51), and a control group (n = 298). The study and control groups were compared for PTS, sex, and age, with ACLR, TEF, OSD, retrospectively. The ACLR, OSD, and TEF groups had higher PTS values than the control group (P < 0.001). There was no significant difference in ACLR-OSD, ACLR-TEF, and OSD-TEF comparisons (P = 0.22, P = 0.99, and P = 0.99, respectively). PTS increase was linked to ACLR, TEF, and OSD in the multinomial regression analysis, (P < 0.001). Increase in PTS was associated with ACLR, TEF, and OSD for both males and females (independently of other factors; ACLR: P < 0.001, P < 0.001, OR: 1.59, OR: 2.63, TEF: P = 0.001, P < 0.001, OR: 1.98, OR: 1.44; OSD: P = 0.001, P < 0.001, OR: 1.49, OR: 1.28 for males and females respectively). ACLR, TEF, and OSD are associated with increased PTS in the pediatric and adolescent age groups, and there are differences between these pathologies in terms of the amount of PTS increase, age, and sex. Consideration of age and gender in pediatric and adolescent patients with increased PTS may be useful in predicting pathologies associated with increased PTS. Level of evidence: III retrospective comparative study.

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

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

The effect of the distance between the end point of the osteotomy and the lateral cortex on the lateral cortical hinge fracture in medial opening-wedge high tibial osteotomy.

Background The purpose of this study was to compare the effects of different distances between the end point of the osteotomy and the lateral cortex on the risk of lateral cortical fracture in the medial opening-wedge high tibial osteotomy (MOWHTO) procedure. Methods Eighteen synthetic tibia models were used. Saw cuts were performed on the test models (n=6 for all groups). Wedge gap distance and wedge opening load were evaluated using compression tests. Findings The mean maximum gap distance without a lateral cortical fracture was 19.90 mm in Group 5, 15.49 mm in Group 10, and 11.23 mm in Group 15. The differences between Group 5 and Group 10, Group 5 and Group 15, and Group 10 and Group 15 were statistically significant. The mean load just before the fracture was 13.24 N in Group 5, 18.31 N in Group 10, and 26.16 N in Group 15. The difference between Group 5 and Group 15 was statistically significant. No significant difference was observed between Group 10 and both Group 5 and Group 15. Interpretation As the end point of the osteotomy is brought gradually closer to the lateral cortex, wider gaps can be opened without a lateral cortical fracture. Thus, higher angle corrections can be achieved more safely by bringing the end point of the osteotomy closer to the lateral cortex, which should be preferred to reduce the risk of a lateral cortical hinge fracture during the MOWHTO procedure, from a clinical viewpoint.

Return to sport rate following sports trauma-related delayed bucket-handle meniscus repair with concomitant ACL reconstruction.

BACKGROUND: Return to sports rate of chronic meniscus repair concurrent with Anterior Cruciate Ligament (ACL) reconstruction remains unclear, especially there is no well-defined return to sports criteria for evaluation. The purpose of this retrospective study was to determine the success rate of chronic locked bucket-handle meniscal tear (BHMT) repair with concomitant ACL reconstruction. METHODS: This study includes 51 chronic ACL injury patients with a locked meniscal tear of at least 6 weeks who underwent surgery. All cases were treated with arthroscopic BHMT repair and ACL reconstruction between 2017 and 2020. Patient demograph-ics, chronicity, pre-operative, and intraoperative surgical variables which associated with return to sports were defined. BHMT was repaired with an all-in-side meniscus repair and/or combined repair procedure first, then an anatomic outside-in ACL reconstruction using a suspension device for femoral fixation was performed. Patients underwent same rehabilitation program with the goal of return-ing to sport at approximately 4-8 months. A modified return-to-sport criterion was performed in this study. RESULTS: Fifty-one patients with an average age of 27.4 (range 18-48) years were included in the study. The average time elapsed from the occurrence of locked knee symptoms to surgery was 10.5±4.4 weeks. The mean follow-up time was 25.3±4.5 months. Sig-nificant improvement was observed in all patient-reported outcomes from baseline to the final follow-up. The mean modified Lysholm knee score increased from 45.5 points to 91.5 at the final follow-up (p<0.001). The 43 out of 51 patients (84.3%) were return to their recreational activities (amateur sports). The mean time to return to sport was 5.9±0.8 (5-8) months. CONCLUSION: Majority of the patients who underwent ACL reconstruction with BHMT repair return to their pre-operative activity levels in 8 months. All neglected BHMTs with concomitant chronic ACL rupture should be repaired in a single-stage surgery if the half plane-concave shape of the menisci has been preserved regardless of the delay in time to surgery.

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

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

Morphological structure and variations of fetal lateral meniscus: the significance in convenient diagnosis and treatment.

PURPOSE: The aim of this study is to evaluate of morphometry of the lateral meniscus (LM) and determine incidence of the LM shapes. METHODS: This study was performed on fetal cadaver collection of Anatomy Department of Necmettin Erbakan University. Fifty human fetal cadavers (25 female, 25 male human fetal cadavers) were used in this study. Microdissection was performed. Morphometric measurements were performed. LM were classified into four types and five subtypes. RESULTS: In this study, it was identified that all parameters which were measured were found to be increased with gestational ages. Four morphological types and five morphological subtypes were determined. It was found that 12% of the LM were crescent-shaped, 66% of the LM were C-shaped, 14% of the LM were incomplete-disc-shaped, 2% of the LM were disc-shaped, 6% of the LM were variant C-shaped. CONCLUSIONS: A few studies on fetal meniscal anatomy and its development were performed. Each new study is important for having detailed anatomy and development of the fetal menisci which will have both clinical and anatomical impacts during childhood and adulthood for orthopedic surgeons and anatomists, respectively. The most important results of this study were the detailed objective analysis of the macroscopic fetal growth of LM. It was significantly observed that four morphological types and five morphological subtypes of LM. The results of the present study related with both the observation of morphological development of the fetal meniscal anatomy, and its morphological variants, are important in terms of improving our knowledge, and clinical approach on the description, and the management of the symptomatic lateral discoid meniscus tears in children, adolescents, and adults. The clinical relevance of this study was that this classification of fetal menisci could ameliorate our current understanding of the morphology of lateral meniscus in adult, further.

Modern treatment of meniscal tears.

The complex ultrastructure of the meniscus determines its vital functions for the knee, the lower extremity, and the body.The most recent concise, reliable, and valid classification system for meniscal tears is the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) Classification, which takes into account the subsequent parameters: tear depth, tear pattern, tear length, tear location/rim width, radial location, location according to the popliteal hiatus, and quality of the meniscal tissue.It is the orthopaedic surgeon's responsibility to combine clinical information, radiological images, and clinical experience in an effort to individualize management of meniscal tears, taking into account factors related to the patient and lesion.Surgeons should strive not to operate in most cases, but to protect, repair or reconstruct, in order to prevent early development of osteoarthritis by restoring the native structure, function, and biomechanics of the meniscus.Currently, there are three main methods of modern surgical management of meniscus tears: arthroscopic partial meniscectomy; meniscal repair with or without augmentation techniques; and meniscal reconstruction. Meniscus surgery has come a long way from the old slogan, "If it is torn, take it out!" to the currently accepted slogan, "Save the meniscus!" which has guided evolving modern treatment methods for meniscal tears. This last slogan will probably constitute the basis for newer alternative biological treatment methods in the future. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170067.

Editorial Commentary: Arthroscopic Fixation of Tibial Eminence Fractures-Which Technique Is the Best Has Not Been Defined Yet!

The tibial eminence fractures are most frequently observed in children and adolescents increasingly. Their classification and management are mainly made by the displacement of the fracture fragment. The surgical management has evolved from open to arthroscopic techniques. Various fixation techniques have been defined. Mainly, there are 2 types of fixation: screw and suture-based methods. Although recent studies have demonstrated the biomechanical advantages of newer suture-based fixation methods, the best method of fixation has not been defined, yet. Currently, nondisplaced and reducible fractures are managed nonoperatively, and displaced and irreducible fractures are managed operatively. Until the best surgical method is defined by higher level of evidence studies clinically, functionally, radiologically, and biomechanically, the type of fixation will be chosen by considering the experience of the surgeon, the clinical status of the patient, the availability of the implants, and the morphology of these fractures.

Peritoneum and omentum are natural reservoirs for chondrocytes of osteochondral autografts: A comparative animal study.

OBJECTIVE: The purpose of this study was to investigate the effects of the omentum, peritoneum, paratenon and skeletal muscle on the proliferation of the cartilage tissue using rabbit model as an in vivo culture medium. METHODS: 6 months old forty-five New Zealand rabbits were randomized into omentum, peritoneum, muscle, and Achilles paratenon groups. Standard sized osteochondral grafts were harvested from right knees and immediately placed into the specified tissues. Control group was fresh cartilage at the end of follow-up. After five months, samples were collected and evaluated macroscopically by measuring their dimensions (vertical = D1, horizontal = D2, and depth = D3) and volumes, and histologically by counting the chondrocyte number using camera lucida method. RESULTS: Macroscopically, increase in mean values for D1 and D2 dimensions of specimens from paratenon and omentum compared to pretransplant dimensions was statistically significant (p < 0.05). Although, volume measurements were higher in omentum and peritoneum group compared to pretransplant dimensions, increase was not significant (p > 0.05). Histologically, mean chondrocyte count was 14.0 ± 0.6 in fresh articular cartilage. Mean chondrocyte counts were 14.4 ± 0.9 in omentum group, 15.4 ± 1.0 in peritoneum group, 9.7 ± 1.3 in muscle group and 9.2 ± 0.4 in Achilles paratenon group respectively. However, mean chondrocyte counts were higher in samples of omentum and peritoneum group compared to fresh articular cartilage, increase was not statistically significant (p > 0.05). DISCUSSION: Transplantation of the cartilage grafts into mesothelium enhanced the chondrocyte counts and volumes compared with the pretransplant measurements. Mesothelium may have the potential to be used as an in vivo culture medium for osteochondral tissue growth.

Focal anatomic resurfacing implantation for bilateral humeral and femoral heads' avascular necrosis in a patient with Hodgkin's lymphoma and literature review.

INTRODUCTION: The femoral and humeral heads are among the most common sites of osteonecrosis. The aims of this case report was to report three years' results for sequential treatment of bilateral, concomitant involvement of humeral and femoral heads with focal anatomic resurfacing implantation in a single patient with Hodgkin's lymphoma and to review the relevant literature, which is relatively scarce. PRESENTATION OF CASE: We present a 48-year-old male patient with concomitant, bilateral femoral and humeral head avascular necrosis. He was diagnosed as Hodgkin's lymphoma in 1984. He had bilateral groin and shoulder pain, lasting for three years and aggravated by joint motions. Radiological evaluations demonstrated bilateral focal osteonecrosis of femoral heads and humeral heads, respectively. Despite conservative treatment, he did not obtain any symptomatic relief. Following the common decision, he was treated with sequential implantations with the HemiCAP(®) device for both bilateral pathologies, by a single surgeon and standard surgical approaches. Neither intraoperative nor postoperative complication was encountered. After the follow-up period of 36 months after the last surgery, he was symptomless and with normal range of motion for all four joints. DISCUSSION: The bilateral, concomitant involvement of humeral and femoral head in the setting of avascular necrosis is relatively rare. Moreover, the optimal treatment method at earlier stages, in young patients has not been established yet. CONCLUSION: This study is the first report to present the three-years' clinical result of a single, relevant case, who was treated with sequential focal anatomic resurfacing implantations (HemiCAP(®)) in four aforementioned joints.

Treatment of osteonecrosis of the femoral head with focal anatomic-resurfacing implantation (HemiCAP): preliminary results of an alternative option.

BACKGROUND: The optimal treatment of osteonecrosis of the femoral head has not been established yet. The aim of this study was to report preliminary clinical results of focal anatomic-resurfacing implantation for the treatment of osteonecrosis of the femoral head. METHODS: Five patients (four male, one female) with seven surgical procedures, ages between 37 and 52 with an average age of 45.2 (+/- 7.2), diagnosed as femoral head avascular necrosis and who were unresponsive to conservative management or had failed previous surgical treatments were treated with a focal anatomic femoral head resurfacing between the years 2011-2012 and were retrospectively reviewed. Five patients with at least two years of follow-up, one left hip, two right hips, and two patients with bilateral hip surgery were included in this review. After safe surgical dislocation of the hip, full exposure of the femoral head was established. A focal-resurfacing implant matching patient anatomy and femoral head curvature was performed accordingly. Neither intraoperative or postoperative complications nor revision ensued. Visual analogue scores and Harris Hip Scores were recorded both preoperatively and at postoperative 2 years for all seven surgeries. RESULTS: The mean follow-up period was 26.6 +/- 3.8 months, with a range between 24-33 months. The mean visual analogue scores were 8.9 +/- 0.9 preoperatively and 2.3 +/- 1.0 postoperatively at year two (p = 0.017). Harris Hip Scores at postoperative follow-up were found to improve significantly from good to excellent scores (86.0 +/- 7.9), compared with preoperative poor scores (26.7 +/- 11.8) (p = 0.018). The clinical improvements in visual analogue scores (VAS) and Harris Hip Scores were also found to correlate with each other (p < 0.05). CONCLUSIONS: In the present study, the alternative technique of focal anatomic hip resurfacing with HemiCAP® yielded preliminary successful results for the treatment of osteonecrosis of the femoral head. To the best of our knowledge, this is the first case series in the literature, reporting functional clinical results with the use of a focal anatomic-resurfacing implant for the treatment of focal femoral head osteonecrosis.

The biomechanical and histological effects of platelet-rich plasma on fracture healing.

PURPOSE: Platelet-rich plasma (PRP) includes growth factors and proteins that accelerate and stimulate bone regeneration and tissue recovery. The aim of this study was to evaluate the effects of PRP on fracture healing in terms of biomechanics and histology. METHODS: Seventy female rats were included in this experimental study. They were divided into three groups: Group I (no PRP, n = 30), Group II (PRP added, n = 30) and Group III (control, n = 10). The left femurs of the rats in Groups I and II were osteotomized and fixed by K-wires. Although no additional intervention was performed on Group I rats, PRP was applied to the fracture sites of Group II rats. The remaining ten rats were used as the control group of the biomechanical test (Group III). In the fourth week, nine femurs from Group I and ten femurs from Group II, and in the ninth week, nine femurs from each group were removed, and bone recovery was assessed histologically according to Modified Lane-Sandhu histological scoring criteria. Three-point bending test was applied to femurs for biomechanical evaluation in the ninth week. RESULTS: Histological healing was found to be significantly higher in Group II than in Group I (p < 0.05). Furthermore, biomechanical test results showed that healing quantity and bone strength were significantly better in Group II than in Group I (p < 0.05). CONCLUSION: PRP is a widely studied material in the physiology of fracture healing. The results of this study demonstrated the ameliorative biomechanical effects of PRP on fracture healing, in addition to accelerating the histological union of fractures. In the light of these results, PRP could be a viable alternative to accelerate the healing of fractures, late unions or non-unions. LEVEL OF EVIDENCE: Prospective comparative study, Level II.

Ultrasound-guided multiple peripheral nerve blocks in a superobese patient.

The number of obese patients has increased dramatically worldwide. Morbid obesity is associated with an increased incidence of medical comorbidities and restricts the application choices in anesthesiology. We report a successfully performed combined ultrasound-guided blockade of the femoral, tibial, and common peroneal nerve in a superobese patient. We present a case report of a 31-year-old, ASA-PS II, super obese man (190 kg, 180 cm, BMI: 58 kg/m(2)) admitted to the emergency department with a type II segmental tibia shaft fracture and ankle dislocation after a vehicle accident. After two failed spinal anesthesia attempts, we decided to apply a femoral block combined with a sciatic block. Femoral blocks were successfully performed with US guided in-plane technique. Separate blocks of the tibial and common peroneal nerves were planned after the sciatic nerve could not be located due to the thick subcutaneous tissue. We performed a tibial nerve block at 2 cm above the popliteal crease and common peroneal nerve at the level of the fibular head with US guided in-plane technique. The blocks were successful and no block-related complications were noted. Ultrasound guidance allows new approaches for multiple peripheral nerve blocks with low local anesthetic doses in obese patients.

Arthroscopy-assisted reduction versus open reduction in the fixation of medial malleolar fractures.

PURPOSE: Purpose of this case-control study was to evaluate the feasibility and advantages of arthroscopically assisted reduction and internal fixation of isolated medial malleolar fractures and compare the outcomes with conventional open reduction and internal fixation. METHODS: Forty-seven patients with medial malleolar fractures were grouped into two: arthroscopy-assisted group, and conventional open reduction and internal fixation group. Arthroscopic treatment group consisted of 21 patients. The mean age was 34 years (range: 22-49 years). Conventional open reduction and internal fixation group included 26 patients. The mean age was 42 years (range: 22-58 years). According to Herscovici system, 6 fractures in the arthroscopy group were classified as type-B, 13 fractures as type-C, and 2 fractures were classified as type-D. In both groups, fractures were classified according to Herscovici system. Radiological and clinical outcomes were evaluated according to van Dijk classification and Olerud-Molander scoring system, respectively. RESULTS: The mean follow-up period was 26 months (18-52 months) for arthroscopically assisted group and 38 months (24-58 months) for the conventional group. According to van Dijk classification, there was only one patient with Grade 1 osteoarthritic changes in arthroscopically assisted group compared with the conventional group where two patients had Grade 2 and one patient had Grade 1 osteoarthritic changes. Median Olerud Scores were 92.3 (75-100) and 86.3 (70-100) for the arthroscopically assisted group and for the conventional group, respectively. The difference was statistically significant (p = 0.015). CONCLUSIONS: With the use of arthroscopically assisted techniques in fixation of isolated medial malleolar fractures, surgeon can evaluate intra-articular surface and reduction that may be of value in the improvement in clinical outcomes over conventional surgical treatment. LEVEL OF EVIDENCE: Case-control study, Level III.

Retroperitoneoscopic drainage of complicated psoas abscesses in patients with tuberculous lumbar spondylitis.

PURPOSE: Nowadays, endoscopic techniques are widely used in surgical procedures. Retroperitoneoscopy has been an extremely valuable tool for a wide variety of urologic disorders, whereas, it has limited use in orthopedic procedures. METHODS: We performed retroperitoneoscopic drainage (in combination with medical treatment) of complicated psoas abscess on 12 patients with tuberculous spondylitis. All the procedures were done under general anesthesia and in the lateral decubitus position. Psoas abscess was evacuated during procedure, and postoperatively, drainage was continued through a large silastic tube. The definitive diagnosis and the treatment were made based on the results of culture-antibiogram and PCR testing. RESULTS: Complete clinical and radiologic remission was observed in all patients in 3-6 months. The complication was not observed in any case postoperatively. CONCLUSIONS: Retroperitoneoscopic drainage of psoas abscesses gains advantages in terms of rapid recovery, minimal invasiveness, absence of radiation, and shorter hospital stay. This procedure can be used not only for cold abscesses but also for other pathologies of lumbar vertebral area.

The effects of the synovium on chondrocyte growth: an experimental study.

PURPOSE: The objective of this study was to evaluate the effects of synovium on the proliferation of the cartilage tissue and chondrocytes using a rabbit knee model as an in vivo synovial culture medium. METHODS: Twelve New Zealand rabbits were used as the animal model in this investigation. Standard size chondral and osteochondral cartilage grafts were taken from, respectively, the left and right knees of all the animals. Two groups of 6 animals were formed: in Group I (synovium group), grafts were placed into the synovial tissue and in group II (patellar tendon group) behind the patellar tendon of the corresponding knees. After 4 months, samples were collected and evaluated macroscopically by measuring their dimensions (vertical = D1, horizontal = D2, and depth = D3) and volumes, and histologically by counting the chondrocyte number using camera lucida method. RESULTS: Macroscopically, the increase in average D1, D2, and D3 measurements and volume in the osteochondral specimens were significantly higher compared to the chondral specimens in both groups (P < 0.05). However, no significant difference was observed between the two groups in terms of macroscopic values. Histologically, the mean chondrocyte counts in osteochondral and chondral specimens for Group I (synovium) were 20.2 and 18.1, and for Group II (patellar tendon) were 18.7 and 15.6, respectively. The mean number of chondrocytes was found to be significantly higher in osteochondral specimens than that of chondral specimens in either group (P < 0.05). Overall average chondrocyte count was significantly higher for Group I compared to Group II (P < 0.05). CONCLUSION: Transplantation of the cartilage grafts into the synovial tissue in rabbit knees significantly enhanced the chondrocyte production compared with the group where the grafts were transplanted into intra-articular patellar tendon. The results of this study indicate that native synovial tissue may have the potential to be used as an in vivo culture medium for osteochondral tissue growth.