Radiographical and clinical results of a new conservative treatment algorithm in Legg-Calvè-Perthes disease: A retrospective study.

OBJECTIVE: This study aimed to establish a feasible conservative treatment algorithm for Legg-Calvè-Perthes Disease (LCPD), clarify its limitations, and evaluate the correlations between radiographical and clinical results. METHODS: Patients diagnosed with LCPD and treated conservatively were evaluated retrospectively; 39 hips from 35 patients were included. The treatment protocol consisted of intermittent manual traction, range of motion exercises, activity limitation, bed rest, NSAID (ibuprofen 100mg/5mL), and ASA (100mg/day) during attack periods. The treatment protocol was standardized, and an algorithm was established for all the patients. RESULTS: The mean follow-up was 13.7 (range = 8-22) years. According to the Stulberg classification, 26 (67%) hips were good, 6 (15,3%) were fair, and 7 (17%) were poor. No activity-limiting pain was detected in any patient. The mean Harris score was 90.5 ± 5.3 for Stulberg type 1, 2, and 3 hips, but 84.2 ± 8.8 for Stulberg type 4 and 5 hips. When the patients were evaluated in terms of pain, activity, and func- tion, it was seen that pain and activity were not different, especially in the Stulberg 1, 2, 3, and 4 patients during the mid-term follow-up. The function was the main factor correlating with the Stulberg classification. Twenty-nine (82.8%) families defined the applicability of the treatment protocol as "easy," 4 (10.3%) defined it as "moderate," and 2 (6.2%) defined it as "difficult." CONCLUSION: The present study demonstrated that the treatment protocol was successful and easily applicable to LCPD. Although lateral pillar classification was efficient to predict radiographic results, the Stulberg classification was not correlated with the clinical results for every subgroup. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

A legal overview of the use of messaging platforms in healthcare.

Medical interventions are becoming more complex day by day. Moreover, compared with the past, more healthcare professionals take part in the same intervention in the field of medicine. The use of technology in medical interventions has also increased. This change in the health sector brings together several legal discussions. In this study, the legal consequences that arise from the treatment processes carried out by the residents and resident educators (registerers / attending physicians), the exchange of information between them, and the usage of some messaging platforms, especially WhatsApp, in this process will be analyzed.

Ultrasonographic comparison of bilateral patellar tendon dimensions in patients treated via intramedullary tibial nailing using a transpatellar approach.

OBJECTIVE: One of the most common complications following intramedullary nailing of a tibial shaft fracture is anterior knee pain. The etiology of pain remains unclear. Patellar tendon entry point is the most suspected reason for anterior knee pain. This study, sonographically examined the patellar tendons of patients treated via intramedullary nailing. METHODS: Thirty-two patients with a tibial shaft fracture requiring intramedullary nailing via a transpatellar approach were included in the study. After all patients were grouped by reference to the presence of anterior knee pain, bilateral patellar tendon ultrasonography was performed. RESULTS: Thirty-two patients were included in the study. Patients were measured postop average in 38.3 months (10th months - 84th months). It was determined that 10 patients of total 32 (31.3%) had anterior knee pain. There were no statistically differences between study groups in the length of patellar tendon. In the painless group; patellar tendon was wider and thicker in the operated side than the non operated side. The mean differences in the thickness between operated side versus non - operated side of the painless group were 5.3 ± 1.8 in the operated side and 3.9 ± 1.4 in the non - operated side (p = 0.007 < 0.05). The corresponding values for width of the patellar tendon was 29.6 ± 3.3 in the operated side and 27.6 ± 3.8 in the non - operated side (p = 0.007 ˂ 0.05). As a result, there were no statistically significant differences between width and thickness of the patellar tendons in the painful group, on the contrary, in the painless group; patellar tendons were wider and thicker in the operated side than those in the non - operated side. Mean values for thickness of the operated and non-operated side were 5.9 ± 2.3 and 4.2 ± 2.0, respectively (p = 0.059 > 0.05). Mean values for width of the operated and non-operated side were 30.2 ± 4.5 and 28.5 ± 4.0, respectively (p = 0.103 > 0,05). CONCLUSION: Based on the ultrasonographic investigation of their patellar tendons after intramedullary nailing of a tibial shaft fracture, in the painless patients group; the patellar tendon was wider and thicker in the operated side than the non - operated side, however, in the painful patients there were no statistically significant differences between this parameters. Although the number of patients was not sufficient to conclude precise relation between patellar tendon entry point and anterior knee pain, we determined that thicker and wider tendon might be less related to anterior knee pain. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Effect of Repeated Sterilization by Different Methods on Strength of Carbon Fiber Rods Used in External Fixator Systems.

OBJECTIVES: We aimed to study the effects of repeated sterilization, using different methods, on the carbon fiber rods of external fixator systems. METHODS: We used a randomized set of 44 unused, unsterilized, and identical carbon fiber rods (11 × 200 mm), randomly assigned to 2 groups: unsterilized (4 rods) and sterilized (40 rods). The sterilized rods were divided into 2 groups, those sterilized in an autoclave and those sterilized using hydrogen peroxide. These were further divided into 5 subgroups based on the number of sterilization repetition to which the fibers were subjected (25, 50, 75, 100, and 200). A bending test was conducted to measure the maximum bending force, maximum deflection, flexural strength, maximum bending moment and bending rigidity. We also measured the surface roughness of the rods. RESULTS: An increase in the number of sterilization repetition led to a decrease in maximum bending force, maximum bending moment, flexural strength, and bending rigidity, but increased maximum deflection and surface roughness (P < 0.01). The effect of the number of sterilization repetition was more prominent in the hydrogen peroxide group. CONCLUSIONS: This study revealed that the sterilization method and number of sterilization repetition influence the strength of the carbon fiber rods. Increasing the number of sterilization repetition degrades the strength and roughness of the rods.

A Scoring System to Demonstrate the Risk for Bone Injury in Patients with Clinically Suspected or Occult Scaphoid Fracture.

BACKGROUND: It is important to diagnose a scaphoid fracture accurately and start the correct treatment in the shortest time possible. However, the fracture of bone may not be visible on x-ray. In such cases, patients are clinically diagnosed with suspected or occult scaphoid fractures. The aim of this study was to define a scoring system based on physical examination to demonstrate the risk for bone injury in patients with clinically suspected and occult scaphoid fractures with negative radiographs and anatomical snuff box tenderness and to decrease the costs and workforce loss due to unnecessary treatment and magnetic resonance imaging (MRI). MATERIALS AND METHODS: Patients were initially evaluated by the attendant orthopedic physician in the emergency service with X-ray of the wrist, and ten wrist physical examination techniques were used. The X-rays of patients were evaluated by three orthopedic surgeons. Finally sixty patients, who were diagnosed as having no fracture by all three orthopedic surgeon, were included in the study. The wrists of these patients were evaluated with MRI. RESULTS: There were 46 male (77%) and 14 female (23%) patients with a mean age of 21.5 years (range 7-61 years). About 3.3% had triquetrum fracture, 15% had bone edema in the scaphoid and radius, 18.3% had distal radius fracture, 31.6% had scaphoid fracture, and 31.8% had no bone injury. A scoring system was also proposed. It can be predicted that in the physical examination of the wrist if the total score is higher than 6.5, the probability of fracture is 2.87 (positive likelihood ratio) fold compared to scores below 6.5. CONCLUSIONS: Proposal of this new scoring system was thought to be useful for predicting the risk for bone injury in patients with clinically suspected scaphoid fractures and making decision regarding therapeutic options.

Surgical treatment of displaced intraarticular calcaneus fractures using anatomical lateral frame plate.

BACKGROUND: The present study evaluated the results obtained from the anatomical lateral frame plate treatment of displaced intraarticular calcaneus fractures. METHODS: Overall, 14 displaced intraarticular fractures of 13 patients (3 females, 10 males; Mean age, 37.5 years) were included in the present study. Surgery was performed using widened lateral approach and supported by auto grafts following joint line reduction in all patients. They were then fixated by anatomical lateral frame plate. All the joints were stabilized by casting after the operation. All patients were prescribed controlled and full weight bearing at 6-8th and 12th weeks, respectively. RESULTS: Mean follow-up of patients was 28 months. The fractures were classified according to Sanders system. Clinical scoring of the patients was performed according to American Orthopaedic Foot and Ankle Society, Creighton-Nebraska, and Maryland systems. According to these systems, the mean scores of the patients were 83.7, 75.7, and 88.5 respectively. CONCLUSION: In the present study, we have defined the results of anatomical lateral frame plate treatment in patients with displaced intraarticular calcaneus fractures. We have obtained clinically and radiologically satisfactory results with the anatomical compatibility of plate to the lateral surface of the calcaneus.

Radiological and clinical outcomes of medial approach open reduction by using two intervals in developmental dysplasia of the hip.

OBJECTIVE: To evaluate the midterm clinical and radiological outcomes of the medial approach using two intervals for developmental hip dysplasia (DDH). METHODS: The study involved 62 hips of 47 patients (41 girls, 6 boys) treated with medial approach for DDH from 1999 to 2010. The age of the patients at surgery was 18.7 ± 2.25 months. Follow up of the patients was 11.3 ± 3.07 years. The age of the patients at the last follow up was 12.6 ± 1.74 years. According to the Tönnis classification, 13 hips were grade II, 27 hips were grade III and 22 hips were grade IV. Patients were evaluated according to Omeroglu radiological criteria and modified McKay functional criteria. The presence of avascular necrosis (AVN) of the hip was questioned using the KalamchiMacEwen classification. RESULTS: Radiologically, forty eight (77%) hips were evaluated as "excellent", 8 (13%) hips as "good" and 5 (8%) hips as "fair plus" and 1 (%2) hip as "fair minus". Two (3%) patients had type 1 temporary AVN and one (1%) patient had type 4 AVN with coxa magna and overgrowth of the greater trochanter. According to McKay functional criteria, 56 (90%) hips had "excellent" and 6 (10%) had "good" results. Two (3.2%) hips of one patient had to be reoperated with Salter osteotomy and femoral shortening + derotation osteotomy. CONCLUSION: Medial approach using two separate intervals for tenotomy and capsulotomy does not jeopardize the medial circumflex or the femoral vessels and yields satisfactory midterm results for children 18 months old with dysplasia of the hip. LEVEL OF EVIDENCE: Level IV, therapeutic study.

A patellar tendon length conservation method: Biplanar retrotubercle open-wedge proximal tibial osteotomy.

OBJECTIVE: The early-period results of our technique for performing a medial biplanar retrotubercle open-wedge proximal tibial osteotomy for the surgical treatment of varus gonarthrosis were evaluated and compared with those reported in the literature. METHODS: The clinical and radiological results of a medial biplanar retrotubercle open-wedge proximal tibial osteotomy performed on 23 knees in 22 patients with medial gonarthrosis with varus alignment were analyzed. RESULTS: Twenty patients were female and 2 were male. At the time of surgery, the mean age was 56.22 years (44-66 years), the mean body mass index was 31.95 kg/m2 (23.4-44.9 kg/m2), and the mean Hospital for Special Surgery (HSS) score was 68.7 (48-83). The mean preoperative femorotibial anatomical axis angle was 186.39° (173-194°), and the mean Insall-Salvati index value was 1.04 (0.94-1.171). The mean length of follow-up was 30.19 months (6-42 months). At the last follow-up examination, the mean HSS score was 86.48 (74-100), the mean femorotibial anatomical axis angle was 175° (168-171°), and the mean Insall-Salvati index value was 1.06 (0.857-1.32). Comparison of the final follow-up values with the preoperative values demonstrated significant improvement in the HSS score and femorotibial anatomical axis angle, but no significant difference in the Insall-Salvati index value. CONCLUSION: The results of this study indicated that frontal and sagittal plane deformities in patients with varus gonarthrosis can be treated with biplanar retrotubercle open-wedge proximal tibial osteotomy with good clinical results that achieve patellar tendon length stability and avoid patellofemoral problems.

Arthroscopic Technique for Treatment of Schatzker Type III Tibia Plateau Fractures Without Fluoroscopy.

Accurate reduction and maintenance of the stability with correct implant positioning is critical for surgical treatment of tibial plateau fractures. Our technique includes an arthroscopic reduction and fixation of Schatzker type III tibial plateau fractures with a bulls-eye screw placement without fluoroscopy control. With the arthroscopic guidance, an anterior cruciate ligament drill guide is placed and a K-wire sent to the midpoint of the depressed fragment through the guide at a 40° angle to the coronal axis of the tibia. A tunnel is created with the drill over the K-wire. The depressed fragment is further augmented with gentle impacts over the K-wire. After arthroscopic reduction control, an appropriate-sized iliac graft is pushed until it is below the depressed fragment. The targeting device is adjusted at 130° so that it is parallel to the joint line and a K-wire sent through the device so that it would pass just below the graft. The graft is then supported with cannulated screws sent over the K-wire. This technique provides an arthroscopic reduction of the chondral surface and precise placement of the rafting screws without fluoroscopy.

Rhabdomyolysis after tourniquet use in proximal tibial osteotomy: a case report and review of the literature.

Rhabdomyolysis following pneumotic tourniquet use is an extremely rare complication. In this case report, we aimed to present an unusual tourniquet complication following proximal tibial osteotomy. A 55-year-old female patient was operated on for genu varum in our clinic. Postoperatively, an anuria developed, and liver and kidney function test levels increased. The patient was diagnosed with acute rhabdomyolysis, and an aggressive treatment was begun.

Effect of N-butyl cyanoacrylate on fracture healing in segmental rat tibia fracture model.

BACKGROUND: Comminuted fractures can occur due to severe traumas. The treatment of these fractures that may cause serious morbidity and sometimes mortality is N-butyl cyanoacrylate. It has been reported that this adhesive provides sufficient rigid fixation for bone healing. This study aims to examine cyanoacrylate radiologically and histologically to determine whether it provides adequate recovery in segmental fractures. The secondary objective is to evaluate N-butyl cyanoacrylate, an adhesive material that can hold the fragments on the fracture line together following reduction. METHODS: Sixteen Sprague-Dawley rats were divided in two groups as control (n = 8) and experimental (n = 8) groups. In the control group, segmental fractures were made and fixated with K-wire. In the experimental group, the same surgical procedure was applied and also fragments were stabilized with N-butyl cyanoacrylate. RESULTS: On the sixth week, we did not see any statistically significant difference in the radiological scoring between groups. However, the pathological scores of the control group were statistically higher than the cyanoacrylate group. CONCLUSIONS: We found that cyanoacrylate was rapidly and easily applied in the segmental fractures but did not cause any superior radiological and clinical results compared to the control group. The cyanoacrylate had low viscosity, and it was not capable enough to fill the defects formed between osteotomy surfaces. However, it did not adversely affect fracture healing as seen in biopsies taken as a result of follow-ups.

The relationship between intra-articular meniscal, chondral, and ACL lesions: finding from 1,774 knee arthroscopy patients and evaluation by gender.

Knowing the relationship between diagnoses is important in knee arthroscopy in terms of defining possible treatment modalities preoperatively. The purpose of our study was to define the diagnoses made intraoperatively through knee arthroscopy and the relationships between them. We evaluated the results of knee arthroscopies performed over a 10-year period. The sites and sizes of chondral lesions, the existence of anterior cruciate ligament (ACL) injury, and the sites of meniscal lesions were noted for a total of 1,774 patients. The relationships between these lesions were evaluated statistically. Chondral lesions and posterior medial meniscal tears were predominant in females, whereas complete ACL tears were predominant in males. ACL tears were commonly accompanied by medial and lateral meniscal bucket-handle tears. In cases with advanced chondral lesions, medial and lateral posterior meniscal and lateral anterior meniscal tears were more common. According to our results, posterior tears of the medial menisci, medial and lateral femoral condyles, lateral tibial plateau type 3 or 4 cartilage lesions, and the rate of diagnostic arthroscopy were higher in females, while middle substance and bucket-handle tears of medial menisci and total rupture of the ACL were more common in males. ACL injuries were seen to coexist with medial or lateral menisci bucket-handle tears, with no relationship between the site or size of the chondral lesions. A relationship between medial and lateral meniscal tears and the site of femoral and tibial chondral surface lesions was detected.

Monoplanar versus biplanar medial open-wedge proximal tibial osteotomy for varus gonarthrosis: a comparison of clinical and radiological outcomes.

PURPOSE: We compared clinical and radiological results of two proximal tibial osteotomy (PTO) techniques: monoplanar medial open-wedge osteotomy and biplanar retrotubercle medial open-wedge osteotomy, stabilised by a wedged plate. METHODS: We evaluated 88 knees in 78 patients. Monoplanar medial open-wedge PTO was performed on 56 knees in 50 patients with a mean age of 55 ± 9 years. Biplanar retrotubercle medial open-wedge PTO was performed on 32 knees in 28 patients with a mean age of 57 ± 7 years. Mean follow-up periods were 40.6 ± 7 months for the monoplanar PTO group and 38 ± 5 months for the biplanar retrotubercle PTO group. Clinical outcome was evaluated using the hospital for special surgery scoring system, and radiological outcome was evaluated by the measurements of femorotibial angle (FTA), patellar height and tibial slope changes. RESULTS: In both groups, post-operative HSS scores increased significantly. No significant difference was found between groups in FTA alteration, but the FTA decreased significantly in both groups. Patellar index ratios decreased significantly in the monoplanar PTO group (Insall-Salvati Index by 0.07, Blackburne-Peel Index by 0.07), but not in the biplanar retrotubercle PTO group. Tibial slopes were increased significantly in the monoplanar PTO group, but not in the retrotubercle PTO group. CONCLUSIONS: Biplanar retrotubercle medial open-wedge osteotomy and monoplanar medial open-wedge osteotomy are both clinically effective for the treatment for varus gonarthrosis. Retrotubercle osteotomy also prevents patella infera and tibial slope changes radiologically.

Minimally invasive reduction technique in split depression type tibial pilon fractures.

Tibial pilon fractures usually result from high energy trauma and present as a challenge to the orthopedic surgeon. Accurate reduction of the joint with meticulous care for the surrounding soft tissues is mandatory. We present a case report in which an anterior cruciate ligament targeting device is used with a minimally invasive technique under arthroscopic and fluoroscopic guidance for Orthopaedic Trauma Association 43-B2.3 type pilon fracture treatment.

Proximal medial tibial biplanar retrotubercle open wedge osteotomy in medial knee arthrosis.

The patellar tendon length changes and patella infera occurs in medial open wedge osteotomies. We hypothesized that patellar tendon length in the sagittal plane would not change in a proximal medial tibial biplanar retrotubercle open wedge osteotomy. Proximal medial tibial biplanar retrotubercle open wedge osteotomies were conducted on 23 knees of 22 patients; the mean patient age was 59 ± 7 years (range, 53-69 years). The surgical procedure used had some technical distinctions from those used in literature. The mean follow-up was 37 ± 11 months (range, 19-58 months). Preoperative and postoperative Hospital for Special Surgery Scoring System (HSS) scores, radiological tibial slope, Insall-Salvati, Blackburne-Peel, and Caton indices, femoro-tibial anatomical axis angle, the angle between the femoral condyle and tibial plateau, and the angle between the tibial plateau and tibial axis were measured and compared statistically. Postoperative HSS scores were statistically higher than the preoperative HSS scores. The femoro-tibial axis angle, the angle between the femoral condyle and tibial plateau, and the angle between the tibial plateau and tibial axes decreased significantly. No statistical difference was observed between the preoperative and postoperative Insall-Salvati, Blackburne-Peel, or Caton indices. When we performed proximal medial tibial biplanar retrotubercle open wedge osteotomy, clinical and radiological recovery was observed but patellar height did not change.

Anatomical frame plate osteosynthesis in Ada-Miller Type 2 or 4 scapula fractures.

OBJECTIVES: The aim of this prospective study was to evaluate the results of anatomical frame plate osteosynthesis in patients with Ada and Miller Type 2 or 4 scapula fractures. METHODS: Eleven Ada and Miller Type 2 or 4 scapula fractures in nine patients were treated with anatomical frame plate osteosynthesis. The mean follow-up time was 39.8 (12-77) months. The results were evaluated using the Herscovici score. RESULTS: No complications, such as neurovascular injury, postoperative hematoma, infection, delayed wound healing, implant failure, delayed union, or nonunion occurred. Based on the Herscovici score, the results were excellent. CONCLUSION: Osteosynthesis with anatomical frame plates appears to be a safe method that allows early range of motion and that provides excellent results in Ada and Miller Type 2 or 4 scapula fractures.

Component alignment in simultaneous bilateral or unilateral total knee arthroplasty.

A bilateral total knee prosthesis procedure can be performed simultaneously in patients with bilateral gonarthrosis. The purpose of this study was to evaluate the differences in component alignment between the simultaneous bilateral TKA and unilateral TKA. A total of 20 patients out of 40 underwent simultaneous bilateral TKA, whereas 20 patients had unilateral TKA. The component alignments were compared radiographically. There was no statistically significant difference in the component alignment between the simultaneous bilateral TKA group and the unilateral TKA group. In conclusion, component alignment of the patients with simultaneous bilateral TKA is similar to that of unilateral TKA.

Tendon, tendon healing, hyperlipidemia and statins.

Both hyperlipidemia and metabolic syndrome have adverse effect on tendon structure. Atorvastatin is most widely used antihyperlipidemic drug. Statins have adverse effects on the tendon. Many studies have analyzed the relationship between atorvastatin and skeletal muscles. Atorvastatin administered after the surgical repair of a ruptured tendon appears to affect revascularization, collagenization, inflammatory cell infiltration, and collagen construction. Therefore, further investigations on the effects of atorvastatin on tendon healing are needed.

The influence of atorvastatin on tendon healing: an experimental study on rabbits.

Hyperlipidemia is a major risk factor for coronary heart disease. The most commonly used antihyperlipidemic drugs are 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitors (statins), of which atorvastatin is one of the most widely used. Little is known about the relationship between tendinopathy and HMG CoA reductase inhibitors (statins) or the effects of atorvastatin use on tendon healing following surgical repair of tendon rupture. We hypothesized that atorvastatin negatively affects this healing process. The Achilles tendons of 16 New Zealand rabbits were ruptured surgically and repaired with sutures. Eight of the rabbits were given oral atorvastatin. The other 8 served as a surgical control group. Six weeks postoperatively, all the rabbits were sacrificed, and the repaired tendons were removed. After standard histological preparation, fibroblastic activity, re-vascularization, collagenization, collagen construction, and inflammatory-cell infiltration were evaluated. On comparing the atorvastatin and surgical control groups, we observed no difference in fibroblastic activity. Although it did not reach statistical significance in our study, a difference was noted in revascularization, collagenization, and inflammatory cell infiltration; and a statistical difference was observed in collagen construction. Doubt remains about the adverse effect of atorvastatin use during tendon healing. Further investigations in animal and human models are needed on the effects of tendon healing when atorvastatin is administered for a longer time frame prior to the injury.