A novel reduction support frame for management of unstable tibial fractures with intramedullary nail: Preliminary report.

BACKGROUND: Management of unstable tibial fractures (UTF) can be challenging due to widening of the proximal and distal metaphyseal zone, soft tissue problems, and poor vascularity. We aimed to compare the effect of novel tibial orthopedic reduction support (TORS) frame constructed by re-used tubular external fixator systems and manual traction with regard to the quality of re-duction, and fracture healing. METHODS: A total of 65 patients who were admitted with UTF and underwent intramedullary nailing were assessed; 43 patients un-derwent manual traction technique, and 22 patients underwent TORS technique. The sagittal and coronal plane angulations were eval-uated in initial postoperative radiographs, and radiologic union scores for tibial fractures (RUST) were compared at follow-up X-rays. RESULTS: The mean age of patients was 43.49±19.09 years in the manual-traction group and 43.41±16.8 years in the TORS group. The mean coronal plane angulation was 1.84±3.16 in the manual traction group and 1.86±4.21 in the TORS group. The mean sagittal plane angulation was 1.19±1.93 in manual traction group and 0.32±0.65 in the TORS group. The number of coronal and sagittal plane angulations >5° was higher in manual traction group than TORS group. The mean RUST was significantly higher in the TORS group than in the manual traction group at 6th, 9th, and 12th-month controls. The union rates were also higher in the TORS group at 9th and 12th-month controls. CONCLUSION: TORS frame is a simple and cheap technique and should be considered as reduction support in the management of UTF by intramedullary nailing.

The effect of the platelet-rich plasma on osteogenic potential of the periosteum in an animal bone defect model.

OBJECTIVES: This study aims to investigate whether plasma-rich plasma (PRP) enhances the osteogenic potential of periosteal grafts used to repair bone defects and maintains both histologically and biomechanically more durable bone tissue. MATERIALS AND METHODS: A standard bone defect was formed to the left femurs of 54 Sprague-Dawley rats and three groups were formed. In the first group (n=18), no periosteal repair was done for bone defect. In the second group (n=18), periosteal graft tissue was sutured to cover the defect entirely. In the third group (n=18), before periosteal repair, a 1 mL of PRP fibrin was applied into the bone defect. All femoral specimens were compared histologically at four and six weeks and biomechanically by three-point bending test at six weeks after treatment. RESULTS: In the PRP applied group, healing of the bone defect at four weeks was significantly better than the other groups in terms of histological new bone formation (p<0.05). At six weeks, new bone formation in both of the periosteum preserved groups was superior to the first group (p<0.05, for both). There was no statistically significant difference between the second and third groups at the end of the sixth week in the biomechanical analysis, although both groups were significantly stronger than the first group (p<0.05). CONCLUSION: Stimulation of the periosteum with PRP application causes early osteogenic differentiation of precursor cells. Although, at biomechanical basis, PRP application does not create any significant difference, in the recovery of the bone defects at very early period, application of PRP may play a role to accelerate fracture healing and to decrease nonunions.

Analysis of factors among 30-day and 1-year mortality rates in patients with borderline stable-unstable intertrochanteric hip fracture.

OBJECTIVE: This study aimed to evaluate the possible effects of surgical procedures on mortality and to identify the possible risk factors for mortality in the management of geriatric hip fractures. METHODS: A total of 191 patients (105 women and 86 men; mean age 82.26±9.681 [60-108] years) with AO/OTA 31A2.2 intertrochanteric fractures and treated with sliding hip screw, proximal femoral nail, or hemiarthroplasty were included in this retrospective cohort study. The treatment type was decided by the responsible surgeon according to the patients' pre-injury activity level, bone quality, and features of the fracture. Age, sex, type of fracture, type of surgery performed, American society of anesthesiology (ASA) grade, type of anesthesia, time to surgery, type of physical therapy, length of hospital stay, and number of comorbidities were documented. We evaluated the 30-day and 1-year mortality of patients treated with sliding hip screw (SHS), proximal femoral nail antirotation (PFN-A), or hemiarthroplasty and identified the possible risk factors for mortality. RESULTS: A total of 49 patients underwent SHS, 58 underwent PFN-A, and 84 underwent hemiarthroplasty. Of these, 2 patients with SHS, 2 with PFN-A, and 11 with hemiarthroplasty died within 30 days after surgery, whereas 7 patients with SHS, 15 with PFN-A, and 23 with hemiarthroplasty died 1 year after surgery. The 30-day and 1-year overall mortality rates were 7.9% and 23.6%, respectively. Both the 30-day and 1-year mortality risks were higher in patients undergoing hemiarthroplasty than in patients undergoing SHS (p=0.068 versus 0.058). The 30-day mortality was higher in patients receiving general anesthesia than in those receiving combined spinal and epidural anesthesia (p=0.009). The 1-year mortality risk was higher in patients with ASA grade 4 than in those with grade 1 and 2 (p=0.045). Advanced age (p=0.022) and male sex (p=0.007) were also found to be the risk factors for 1-year mortality. CONCLUSION: We demonstrated that higher ASA grade, male sex, general anesthesia, and hemiarthroplasty procedures are associated with higher mortality rates in elderly patients with hip fractures. Thus, we highly recommend orthopedic surgeons to consider all these factors in the management of intertrochanteric hip fractures in the geriatric population. LEVEL OF EVIDENCE: Level IV, Prognostic Study.

Comparison of Kinesiotaping, Exercise and Subacromial Injection Treatments on Functionality and Life Quality in Shoulder Impingement Syndrome: A Randomized Controlled Study.

PURPOSE: Disturbance of scapulohumeral rhythm has been shown to play a major role in subacromial impingement syndrome. Exercise, taping and subacromial injection are first ray conservative treatment modalities. We aimed to correct scapulohumeral rhythm with kinesio taping and exercise program via focusing on especially periscapular muscles not on glenohumeral structures to achieve scapulothorasic stabilization. MATERIAL AND METHODS: Seventy five patients were divided into three groups randomly with different treatment modalities which are only exercise group (Group 1), kinesiotaping + exercise group (Group 2), and injection + exercise group (Group 3). Western Ontario Rotator Cuff Index (WORCI), Quick Disability of arm, shoulder, hand (Q-DASH), Constant- Murley Scores (CMS) were evaluated for each patient at the beginning, 15th and 60th days and compared in time and technique manner. Scores were analyzed statistically with One-way ANOVA and Chi-square tests. RESULTS: All the three groups had better results in short and long term follow ups as compared to initial admission. But in the second group 15th and 60th day results were superior to other groups significantly (p < 0,001). CONCLUSIONS: Most of recent studies using kinesio taping were focused on mechanical correction of humerus which will be an impaired treatment to correct the main cause of impingement. Not only mechanical correction of periscapular muscles and also stabilization of scapulae will help to gain scapulohumeral rhythm.

Comparison of functional outcomes in patients fixed with dynamic hip screw and proximal femur nail-anti-rotation in A1 and A2 type intertrochanteric femur fractures.

BACKGROUND: We aimed to compare clinical and functional outcomes between patients treated with Dynamic hip screw (DHS) and Proximal Femoral Nail-Antirotation (PFN-A) implants. METHODS: This study included 122 patients (66 men [54.1%] and 56 women [45.9%]) who underwent surgery with DHS and PFN-A for an intertrochanteric femur fracture and had at least 12 months follow-up. Reduction assessment, femoral neck-shaft angle and tip-apex distance measurements were performed in early postoperative radiographs. On control visits in months 1, 3, 6 and 12, range of motion, thigh or hip pain, and Trendelenburg positivity were assessed in clinical examination and reduction assessment, femoral neck-shaft angle and tip-apex distance measurements were performed on radiographs after the union. Patients were assessed using Hip Harris Score after the union. RESULTS: Regardless of implant type used, mean tip-apex distance measured at the immediate postoperative period was 27.6 in patients with implant failure, whereas 21.6 in patients without, indicating a significant difference. Again, mean femoral neck-shaft angle measured at the immediate postoperative period was 123 degree in patients with implant failure, whereas 130 degree in those without, indicating a significant difference. It was found that the femoral neck-shaft angle was <128 degree in all patients with implant failure whereas it was >128 degree in 94% of patients without implant failure at immediate postoperative period. CONCLUSION: The findings regarding femur neck-shaft angle at the immediate postoperative period was <128 degree in all patients with implant failure and that it was ≥128 degree in 94% of patients without implant failure emphasize the importance of anatomic restoration in femur neck-shaft angle during surgery. The finding that mean tip-apex distance was 27.6 mm in patients with implant failure and 21.6 mm in patients without implant failure indicates that the technique is as important as implant type selected for treatment success of the implantation.

Mesenchymal stem cells have significant anti-infective effect on methicillin-resistant Staphylococcus epidermidis vascular graft infections.

OBJECTIVES: This study aims to evaluate the effects of mesenchymal stem cell (MSC) implantation on vascular graft infections caused by methicillin-resistant Staphylococcus epidermidis (MRSE) and compare with antibiotic treatment. MATERIALS AND METHODS: Healthy adult 56 Wistar rats (age, over 5 months; weighing, 300-350 g) were divided into eight groups. Group 1 was defined as the control group and group 2 was defined as the infected control group. Groups 3 and 4 were defined as Dacron grafted and MRSE infected groups, treated with tigecycline and MSCs, respectively. Groups 5 and 6 were performed polytetrafluoroethylene (PTFE) graft and infected with MRSE. These groups were also administered tigecycline and MSC treatment, respectively. Groups 7 and 8 were infected with MRSE without graft administration and were also performed tigecycline and MSC treatment, respectively. Grafts and soft tissue specimens were collected at 13 days postoperatively. Colony counts of peri-graft tissue were performed. All samples were evaluated by enzyme-linked immunosorbent assay (ELISA) for the markers that determine stem cell activity. RESULTS: The overall success of the treatments was assessed by the number of rats with MRSE recurrence, regardless of graft used. The difference between the untreated group 2, tigecycline groups (3, 5 and 7) and MSCs groups (4, 6 and 8) were statistically significant. Success of MSC and tigecycline treatments was similar in Dacron, PTFE, and non-grafted groups. There was a resistance of MRSE infection in Dacron groups to MSC and tigecycline treatments. This was considered to be indicative of the susceptibility of the Dacron grafts to infection. However, there was no significant difference between group 2 and Dacron groups in terms of bacterial colonization. ELISA results were significant in three cytokines. CONCLUSION: Mesenchymal stem cells can be considered as an alternative treatment option on its own or part of a combination therapy for control of vascular graft infections.

Comparison of bench-top simulation versus traditional training models in diagnostic arthroscopic skills training.

OBJECTIVES: This study aims to compare the efficacy of existing training models for acquisition of arthroscopic skills and to investigate the most effective training method or combination of methods for residents. MATERIALS AND METHODS: A total of 100 fifth-year students from medical school (40 males, 60 females; mean age 23.7 years; range, 22 to 33 years) volunteered to participate in the study and were randomly divided into five education groups (E1-5): group E1 (trained on bench-top simulator), group E2 (read surgical technique), group E3 (read surgical technique and watched surgical video), group E4 (watched surgical video only), and group E5 (control group). After completion of the pre-training, each student was individually asked to perform an arthroscopy practice. A checklist containing the tasks to be performed was given to students and students were asked to complete the tasks on the checklist in five minutes. RESULTS: In group E1, the mean rate of successful achievement of tasks was significantly higher than other groups in both knee and shoulder arthroscopy models. Rate of each task was statistically similar for groups E2, E3, E4 and E5. In group E1, mean durations for completion of tasks in both arthroscopy models were significantly shorter than other groups. There was no statistically significant difference in terms of gender between those who successfully completed the tasks in both arthroscopy models. CONCLUSION: A basic arthroscopic bench-top simulator may be a low-cost and effective training method to increase arthroscopic skill levels in resident training compared to traditional methods.

Platelet-rich plasma decreases fibroblastic activity and woven bone formation with no significant immunohistochemical effect on long-bone healing: An experimental animal study with radiological outcomes.

PURPOSE: This study aimed to analyze the immunohistochemical effect of platelet-rich plasma (PRP) on healing of long-bone fractures in terms of bone morphogenetic protein-2 (BMP-2), vascular endothelial growth factor (VEGF), the Ki-67 proliferation index, and radiological and histological analyses. METHODS: Sixteen adult rabbits, whose right femoral diaphysis was fractured and fixed with Kirschner wires, were randomly divided into two groups, control and PRP (groups A and B, respectively). PRP was given to group B at 1 week postoperatively, and all animals were euthanized after 12 weeks. Radiographic evaluations were performed periodically. Cortical callus formation, chondroid and woven bone area percentages, osteoblastic and fibroblastic activities, and mature bone formation were examined. The depths of BMP-2 and VEGF staining were measured. The Ki-67 proliferation index was also calculated. RESULTS: The mean radiological union score of group B was significantly higher than that of group A. There were also statistically significant differences between groups A and B in terms of cortical callus formation, woven bone area percentage, fibroblast proliferation, and mature bone formation. Group B had significantly more cortical callus and mature bone formation with less woven bone and fibroblast proliferation. Immunohistochemical analysis revealed no statistically significant difference between the groups in terms of BMP-2 and VEGF staining and the Ki-67 index. CONCLUSIONS: PRP had no effect on BMP-2 or VEGF levels with no increase in the Ki-67 proliferation index, although its application had a positive effect on bone healing by increasing callus and mature bone formation with decreased woven bone and fibroblast proliferation.

The antibacterial effect of mesenchymThe antibacterial effect of mesenchymal stem cells on graft infections: An experimental studyal stem cells on graft infections: An experimental study.

BACKGROUND: In this study, we aimed to investigate the antibacterial effects of mesenchymal stem cells, compared to tigecycline, on graft infection related with methicillin-resistant Staphylococcus epidermidis in a rat model. METHODS: A total of 42 male adult Wistar rats (age >6 months; weight 300 to 350 g) were divided into six groups including seven rats in each. Group 0 did not undergo any procedure; Group 1 was infected, but untreated; Group 2 was infected and treated with tigecycline without graft placement; Group 3 was infected and received mesenchymal stem cells without graft placement; Group 4 was infected and treated with tigecycline after graft placement; Group 5 was infected and treated with mesenchymal stem cells after graft placement. The pockets created were either left empty or implanted with Dacron grafts. Treatment was commenced at 48 h. Specimens were collected on Day 13. Perigraft tissues were evaluated histopathologically and bacterial colony numbers were counted. RESULTS: No bacterial colonization was observed in Group 0, whereas there was a significant colonization in Group 1. Complete eradication was achieved in Group 2 and Group 3 (graft-free groups), and near-complete eradication was achieved in Group 4 and Group 5 (graft-implanted groups). The histopathological findings significantly differed between Group 1-Group 2 and between Group 1-Group 3 (graft-free groups). The histopathological findings were similar between Group 2-Group 3 and between Group 4-Group 5. CONCLUSION: Our study results suggest that mesenchymal stem cells may be a novel, contemporary alternative to antibiotherapy and may decrease the bio-burden of Staphylococcus at the infected graft areas, and mesenchymal stem cell treatment may be as effective as tigecycline.

Comparison of two medial epicondylectomy techniques in cubital tunnel syndrome.

OBJECTIVES: This study aims to compare partial medial epicondylectomy (PMe) and distal medial epicondylectomy (DMe) techniques in terms of sensory and motor improvements, functional results and complications. PATIENTS AND METHODS: The study included a total of 59 cubital tunnel syndrome patients (37 males, 22 females; mean age 42.3 years; range 23 to 80 years). Of the patients, DMe was applied on 30 and PMe was applied on 29. Patients were evaluated with Wilson Krout scores, Semmes-Weinstein Monofilament (SWM) test, and grip and pinch strength measurements preoperatively and at postoperative third, sixth, and 12th months. Both groups' pre- and postoperative intragroup and intergroup results were compared. RESULTS: Wilson Krout scores in postoperative checks were better with DMe compared to PMe. The improvement in SWM test scores was statistically significant for only DMe. The improvement in grip strength, lateral pinch and terminal pinch measurements in DMe group was significant at postoperative third month. In PMe group, significant improvement for these measurements was obtained at postoperative sixth month. The only complication observed with DMe was tenderness developing over the medial epicondyle. Painful subluxation of the nerve associated with paresthesia was detected in four patients in PMe group. CONCLUSION: Compared to PMe, DMe offers more satisfactory subjective results. Motor functional recovery occurs earlier with DMe. DMe appears to have lower complication rates.