A New Concept of Mosaicplasty: Autologous Osteoperiosteal Cylinder Graft Covered With Cellularized Scaffold.

A concern regarding osteochondral autograft transfer for chondral defects is donor-site morbidity of the knee, the most common source of the autograft. To avoid the drawbacks of osteochondral autograft transfer, a cylindrical osteoperiosteal graft harvested from the iliac crest covered by a same-sized cylinder of hyaluronic acid-based polymer scaffold pretreated with bone marrow aspirate concentrate and transferred to the chondral defect recipient site in the exact size for restoration of the subchondral bone and the articular cartilage.

Which design tolerates rotational mismatch better in unicompartmental knee arthroplasty: fixed or mobile bearing?

Unicompartmental knee arthroplasty is an effective method for the treatment of medial compartment osteoarthritis. However, appropriate surgical tech- nique and optimum implant positioning are crucial for a satisfactory outcome. This study aimed to demonstrate the relation between the clinical scores and the alignment of the components in UKA. A total of 182 patients with medial compartment osteoarthritis and treated by UKA between January 2012 and January 2017 were enrolled in this study. Computed tomography (CT) was used to measure the rotation of components. Patients were divided into two groups according to the insert design. These groups were divided into three subgroups according to the angle of the tibia relative to the femur (TFRA) (A): TFRA 0° to 5° either internal or external rotation; (B): TFRA >5° internal rotation, and (C): TFRA >5° external rotation. There was no significant difference between the groups in terms of age, body mass index (BMI) and follow-up period. KSS scores increased as the tibial component rotation (TCR) external rotation increased, but there was no correlation for WOMAC score. (P: 0,039 r: 0,207; P:0,347 r:0,095, respectively) Post-operative KSS and WOMAC scores decreased as TFRA external rotation was increased. (p: 0,001; p:0,001, respectively) No correlation has been observed between femoral component rotation (FCR) internal rotation and post-operative KSS and WOMAC scores. (p: 0,261; p: 0,502, respectively) Any mismatch between the components is better tolerated by mobile-bearing designs compared to fixed-bearing designs. Orthopedic surgeons should take care of rotational mismatch of components, not only the axial alignment of the components.

A Pilot Study of a Novel Fixation Technique for Fixation of Comminuted Patellar Fractures: Arthroscopic-Controlled Reduction and Circular External Fixation.

Patella fractures represent for 0.5 to 1.5% of all bony injuries in adults. Open reduction and the modified tension-band technique is the most common surgical technique used for patellar fractures. The purpose of this study is to present the outcomes of 26 comminuted patellar fractures treated with circular external fixator (CEF) under arthroscopic control and discuss its potential advantages over conventional surgical methods. This retrospective study included 26 patients who had closed comminuted patellar fractures and treated by CEF under arthroscopic control between January 2002 and March 2016. All patients treated with this technique were involved to the study as a consecutive series. Patients with noncomminuted transverse fractures were excluded, because they were treated with a different technique. Of the 26 patients 22 were male, 4 were female with the mean age of 33.5 years (range, 16-56 years). Patients were followed for 20 to 28 months (mean, 22 months). The mean time to union and the duration of fixation with the CEF ring was 12 weeks (range, 6-15 weeks). The mean Lysholm's score was 45 (range, 35-58) at the 10th postoperative day, which increased to 51 (range, 40-68) at the end of the first postoperative month and increased to 95 (range, 90-100) 1 month after CEF ring removal. Minor pin tract infection by pin-skin irritation was observed in nine patients. In one patient, refracture occurred due to a fall 19 days after CEF removal. CEF appears to be a safe and effective treatment for comminuted patellar fractures with a high union rate and minimal complications. It is safe and effective, as it allows short hospital stay and avoids a second surgery for removal of the instrument. Early rehabilitation with full weight-bearing promotes rapid recovery and quick return to work. Patients do not have a large unaesthetic scar on the anterior of the knee.

The relation between ankle morphology and osteochondritis dissecans of talus.

The purpose of this study is to describe, if there is, any relation between ankle morphology and development of talus osteochondritis dissecans (OCD) using certain morphological parameters derived from high resolution magnetic resonance imaging (MRI). Study included a total of 93 patients: 26 patients with traumatic medial talus OCD, 30 patients with idiopathic medial talus OCD and 37 patients with normal ankle as the control group. Five MRI morphological parameters (Maximal Tibial Thickness (MTiTh), Malleolar Width (MalW), Length of Trochlea Tali Arc (TaL), Height of Trochlea Tali Arc (TaH) and Angle of Trochlea Tali Inclination (TaIA)) that are expected to be relevant to talus OCD formation are measured and compared for the three groups. Significant difference was found between the idiopathic and the traumatic group in terms of age and gender. Two of five morphologic parameters (MalW and TaL) also showed significant difference for the traumatic and idiopathic group compared to healthy volunteers. Two morphologic parameters that were found to be significantly different from healthy controls may suggest that ankle morphology be a possible factor for talus OCD. Age and gender difference between the traumatic and idiopathic group also may point out different underlying mechanisms for OCD formation.

A glycosaminoglycan mimetic peptide nanofiber gel as an osteoinductive scaffold.

Biomineralization of the extracellular matrix (ECM) plays a crucial role in bone formation. Functional and structural biomimetic native bone ECM components can therefore be used to change the fate of stem cells and induce bone regeneration and mineralization. Glycosaminoglycan (GAG) mimetic peptide nanofibers can interact with several growth factors. These nanostructures are capable of enhancing the osteogenic activity and mineral deposition of osteoblastic cells, which is indicative of their potential application in bone tissue regeneration. In this study, we investigated the potential of GAG-mimetic peptide nanofibers to promote the osteogenic differentiation of rat mesenchymal stem cells (rMSCs) in vitro and enhance the bone regeneration and biomineralization process in vivo in a rabbit tibial bone defect model. Alkaline phosphatase (ALP) activity and Alizarin red staining results suggested that osteogenic differentiation is enhanced when rMSCs are cultured on GAG-mimetic peptide nanofibers. Moreover, osteogenic marker genes were shown to be upregulated in the presence of the peptide nanofiber system. Histological and micro-computed tomography (Micro-CT) observations of regenerated bone defects in rabbit tibia bone also suggested that the injection of a GAG-mimetic nanofiber gel supports cortical bone deposition by enhancing the secretion of an inorganic mineral matrix. The volume of the repaired cortical bone was higher in GAG-PA gel injected animals. The overall results indicate that GAG-mimetic peptide nanofibers can be utilized effectively as a new bioactive platform for bone regeneration.

Supramolecular GAG-like Self-Assembled Glycopeptide Nanofibers Induce Chondrogenesis and Cartilage Regeneration.

Glycosaminoglycans (GAGs) and glycoproteins are vital components of the extracellular matrix, directing cell proliferation, differentiation, and migration and tissue homeostasis. Here, we demonstrate supramolecular GAG-like glycopeptide nanofibers mimicking bioactive functions of natural hyaluronic acid molecules. Self-assembly of the glycopeptide amphiphile molecules enable organization of glucose residues in close proximity on a nanoscale structure forming a supramolecular GAG-like system. Our in vitro culture results indicated that the glycopeptide nanofibers are recognized through CD44 receptors, and promote chondrogenic differentiation of mesenchymal stem cells. We analyzed the bioactivity of GAG-like glycopeptide nanofibers in chondrogenic differentiation and injury models because hyaluronic acid is a major component of articular cartilage. Capacity of glycopeptide nanofibers on in vivo cartilage regeneration was demonstrated in microfracture treated osteochondral defect healing. The glycopeptide nanofibers act as a cell-instructive synthetic counterpart of hyaluronic acid, and they can be used in stem cell-based cartilage regeneration therapies.

Angiographic evaluation of arterial configuration after acute tibial shortening.

INTRODUCTION: Tibial nonunion with bone and soft tissue loss is a challenging orthopedic problem. Acute tibial shortening is a well-defined technique; however, arterial configuration following acute tibial shortening has not been demonstrated by a clinical study. MATERIALS AND METHODS: Sixteen patients with tibial nonunion and one patient with acute tibial fracture accompanied by bone and soft tissue loss were treated by acute shortening followed by compression or relengthening between 2004 and 2010. Circulation was monitored by intraoperative Doppler ultrasound and hallux pulse oximetry. Arterial configuration was examined by digital subtraction angiography at the seventh postoperative day and by CT angiography at the second year. Bone healing and functional results were evaluated according to Paley's classification, and complications were evaluated according to Dahl's classification. RESULTS: Mean amount of bone loss was 3 ± 1.4 cm (range 1-6 cm); mean size of the soft tissue defects was 7 × 6.8 cm (range 3 × 3 cm-10 × 10 cm). The mean follow-up period was 38 ± 11.3 months (range 24-57 months). The average amount of acute shortening was 5.4 ± 1.6 cm (range 3-8 cm). Average lengthening was 6 ± 1.8 cm (range 4-8 cm), and the mean external fixation index was 1.4 months/cm (range 0.1-3.7 months). There was no detectable change in the arterial configuration of patients with acute shortening up to 4 cm. Minimal arterial bending was observed in patients that 4-6 cm of shortening was performed. Arterial configuration of the patients that 8 cm acute shortening was performed showed increased tortuosity, but the patency was maintained. CONCLUSION: Acute shortening of tibia in nonunions with soft tissue defects allows for primary closure or reduces the need for grafting and secondary operations. Although the amount of acute shortening depends upon intraoperative assessment with Doppler ultrasound and hallux pulse oximetry, acute compression up to 8 cm can be attained in proximal tibia. More than 4 cm of acute shortening leads to increased tortuosity of major arteries rather than kinking, and this new arterial configuration is maintained for up to 2 years with no problem in circulation.

Fluoroscopy for transpedicular screw placement in scoliosis: to what extent can radiation exposure be reduced by the freehand technique?

AIM: In spinal surgery, high doses of radiation are delivered during surgical procedures that require fluoroscopic control. The aim of this study was to determine the amount of radiation delivered from the fluoroscopic unit and also the factors to reduce the amount of radiation during the surgery of adolescent idiopathic scoliosis patients. MATERIAL AND METHODS: In this retrospective study 21 patients with adolescent idiopathic scoliosis treated by transpedicular screws between 2009 and 2012 were enrolled the study. Dose Area Product (DAP) values , number of views obtained during screw placement and other data were retrieved from the medical records of the patients. RESULTS: The mean number of transpedicular screws used was 18. An average of 10,1 vertebrae were instrumented. The mean number of images obtained was 7.76. Mean fluoroscopy time was 7.95 seconds. The total mean DAP was 64.6 cGy.cm < sup > 2 < /sup > . CONCLUSION: The amount of ionizing radiation transmitted to the patient and the surgical team can be reduced by freehand insertion, confirmation of screw position by AP and lateral fluoroscopic views including more than one segment, the use of K-wires as a guide in spinal segments with abnormal pedicular anatomy and neuromonitorization of the patient during the surgical correction of adolescent idiopathic scoliosis.

Comparison of ketamine-low-dose midozolam with midazolam-fentanyl for orthopedic emergencies: a double-blind randomized trial.

OBJECTIVE: Most of the fractures and dislocations are reduced in the emergency setting. Many drugs are available for procedural sedation and analgesia in the emergency department (ED); however, the adverse effects are still a common problem. The aim of our study was to compare the 2 drug combinations. METHOD: We performed a prospective, randomized, double-blinded, placebo-controlled trial of patients presenting to the ED after a traumatic event and required urgent reduction either for a fracture or dislocation. Patients were randomized to midazolam-fentanyl (MF) group or ketamine-low-dose midazolam (KM) group. Hypoxia, duration of hypoxia, need for oxygen, time to onset of sedation, recovery time, pain scores during reduction, and sedation depth were set as primary outcome measures and were recorded. RESULTS: A total of 498 patients who presented to ED with extremity injury and required closed reduction were assessed; 130 of them were approached for eligibility and 69 patients were excluded. The remaining 61 patients were randomized to either KM group (n = 31) or MF group (n = 30). Hypoxia and duration of hypoxia were significantly lower in the KM group compared with the MF group. Patients in the KM group reported significantly lower pain scores during reduction; however, adverse effects were higher compared with MF group. CONCLUSION: Both drug combinations can be effectively used for procedural sedation and analgesia; however, with lower risk for hypoxia and lower pain scores, KM combination stands as a reasonable choice for orthopedic interventions in the emergency unit.

Communication skills training for emergency medicine residents.

OBJECTIVE: To determine the effects of a communication skills training program on emergency medicine residents and patient satisfaction. MATERIALS AND METHODS: Twenty emergency medicine residents attended a 6-week psychoeducation program that was intended to improve their communication skills. The first three sessions of the psychoeducation program consisted of theoretical education on empathy and communication. Other sessions covered awareness, active communication, and empathic skills on a cognitive behavioral basis using discussion, role play, and homework within an interactive group. The effects of the program were assessed using a communication skills scale, empathy scale, and patient satisfaction survey and were reflected by the reduction in the number of undesirable events between doctors and patients in the emergency department. RESULTS: The mean communication skills score increased from 178.7±19 to 189.2±16 after training (P<0.02). Empathy score also increased from 29.5±9 to 30.7±8, but this difference was not statistically significant (P=0.1). The patient satisfaction survey of 576 patients demonstrated increased scores on confidence in the doctor (88.2±14.6-93.6±10.3; P<0.01); the doctor's respect, kindness, and thoughtfulness (90.3±10.8-94.1±16.5; P<0.01); individualized attention (86.7±9.4-93.9±11.1; P<0.01); devotion of adequate time to listening (88.6±12.3-90.8±14.1; P=0.04); and counseling and information delivery (90.1±11.3-92.2±11.7; P=0.02). The number of undesirable events between doctors and patients decreased 75% from 12 to three. CONCLUSION: Participation in a communication skills training program was associated with improved communication skills of emergency medicine residents, increased patient satisfaction, and decreased complaints.

Can mainstream end-tidal carbon dioxide measurement accurately predict the arterial carbon dioxide level of patients with acute dyspnea in ED.

OBJECTIVE: This study was designed to determine whether the mainstream end-tidal carbon dioxide (ETCO2) measurement can accurately predict the partial arterial carbon dioxide (Paco2) level of patients presented to emergency department (ED) with acute dyspnea. METHODS: This prospective, observational study was conducted at a university hospital ED, which serves more than 110 000 patients annually. Nonintubated adult patients presented with acute dyspnea who required arterial blood gas analysis were recruited in the study for a 6-month period between January and July 2010. Patients were asked to breathe through an airway adapter attached to the mainstream capnometer. Arterial blood gas samples were obtained simultaneously. RESULTS: We included 162 patients during the study period. The mean ETCO2 level was 39.47 ± 10.84 mm Hg (minimum, 19 mm Hg; maximum, 82 mm Hg), and mean Paco2 level was 38.95 ± 12.27 mm Hg (minimum, 16 mm Hg; maximum, 94 mm Hg). There was a positive, strong, statistically significant correlation between ETCO2 and Paco2 (r = 0.911, P < .001). The Bland-Altman plot shows the mean bias ± SD between ETCO2 and Paco2 as 0.5 ± 5 mm Hg (95% confidence interval, -1.3165-0.2680) and the limits of agreement as -10.5 and +9.5 mm Hg. Eighty percent (n = 129) of the ETCO2 measurements were between the range of ±5 mm Hg. CONCLUSION: Mainstream ETCO2 measurement accurately predicts the arterial Paco2 of patients presented to ED with acute dyspnea. Further studies comparing mainstream and sidestream methods in these patients are required.

Comparison of GlideScope video laryngoscope and intubating laryngeal mask airway with direct laryngoscopy for endotracheal intubation.

The aim of this study was to determine whether GlideScope video laryngoscope (GVL) and intubating laryngeal mask airway (i-LMA) improve the intubation success rate and could be easily learned and performed by paramedic students when compared with the direct laryngoscopic (DL) method. The study was designed as a prospective randomized crossover trial that included 121 paramedic students. All participants were asked to intubate each Ambu Airway Management Trainer manikins after the lecture and demonstration. Successful intubation was defined as the passage of the tube through the vocal cord within 60 s. At the end of the study, a questionnaire survey was given to all participants about their preferences, and they were requested to define each method on an easy-difficult scale. Successful intubation was achieved by 95 students (78.5%) with DL, 112 students (92.6%) with i-LMA, and 111 students (91.7%) with GVL. Mean time of intubation was 25.06±14 s for DL, 22.32±12 s for i-LMA, and 22.63±10 s for GVL. Success rates of i-LMA and GVL were significantly higher compared with DL (P=0.005 and P=0.006, respectively). No significant difference was determined between i-LMA and GVL in terms of successful intubation (P>0.05). This study showed that GVL and i-LMA provided better intubation success rates and were easier for paramedic students when compared with the classic DL method.

Stress fracture of bilateral tibial metaphysis due to ceremonial march training: a case report.

Stress fractures are caused by repetitive microtraumas that occur during unusual or increased activities. Clinical suspicion is essential for the diagnosis. A twenty-years old soldier was presented with bilateral knee pain and restriction of knee movements after a period of training for ceremonial march. Although plain X-rays were normal, scintigraphy and MRI revealed stress fractures at metaphyseal region of both tibias. History of a patient presenting with persisting joint or bone pain after an unusual repetitive activity should be delicately inquired. Typical history, although pain might be localized to unusual sites, should raise the suspicion of a stress fracture.

[Evaluation of quality of life of female patients after bilateral total knee arthroplasty].

OBJECTIVES: We evaluated the quality of life of female patients following total knee arthroplasty. METHODS: The study included 50 women (mean age 67 years; range 52 to 84 years) who underwent bilateral total knee arthroplasty for primary osteoarthritis of the knee. All the patients were administered the Medical Outcomes Study Short Form-36 (SF-36) and the Knee Society Clinical Rating System (KSCRS) preoperatively and at six weeks, three and six months postoperatively. Particular attention was given to provide patients with sufficient information on surgery and postoperative rehabilitation program. RESULTS: Compared to preoperative scores, all the subscales of both instruments showed significant improvement at six weeks and six months (p<0.05). After six weeks, however, only SF-36 physical function scores continued to improve significantly till the final assessment (p<0.05), whereas the other subscales reflected only maintenance of improvement. Conversely, a consistent significant improvement after six weeks was seen in the pain score of the KSCRS, while the function score representing only maintenance of improvement. CONCLUSION: Significant improvement is achieved in the quality of life of female patients within six weeks after total knee arthroplasty. It appears that, beyond six weeks, this improvement continues to be significant only in the physical function score of the SF-36 and pain score of the KSCRS.

[Evaluation of patient quality of life after total hip arthroplasty]. / Primer kalça protezi uygulanan hastalarda yasam kalitesinin degerlendirilmesi.

OBJECTIVES: We evaluated the effect of total hip arthroplasty on patient quality of life. METHODS: The study included 30 patients (6 men, 24 women; mean age 62 years; range 36 to 82 years) undergoing total hip arthroplasty. The Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36) was administered to the patients before and after 1.5 and 3 months of surgery. Special attention was given to provide the patients with sufficient information on surgery and postoperative rehabilitation program. RESULTS: All the patients returned to their daily activities within six weeks postoperatively. SF-36 scores obtained after three months of surgery showed significant improvement in all SF-36 subscales compared to those obtained preoperatively and 1.5 months after surgery (p<0.05). Postoperative patient satisfaction was not correlated with sex, age, socioeconomic status, and education level of the patients. The presence of accompanying diseases or previous operations did not affect postoperative quality of life scores. CONCLUSION: Quality of life of patients increases substantially following total hip arthroplasty, with a corresponding increase in patient satisfaction.

[Psychological evaluation of patients with benign musculoskeletal system tumors]. / Benign kas-iskelet sistemi tümörü olan hastalarda psikolojik durum degerlendirmesi.

OBJECTIVES: This study was designed to determine to what extent psychological status was affected by sociodemographic characteristics and by being informed about the diagnosis in patients with benign musculoskeletal tumors. METHODS: The study included 112 male patients (mean age 23.8 years; range 20 to 35 years) who were hospitalized for benign tumors of the musculoskeletal system. A questionnaire was administered to all the patients concerning their sociodemographic characteristics and the status of their knowledge about the diagnosis. Psychological status was assessed by the Hamilton Depression Evaluation Scale. RESULTS: The depression level was not correlated with the localization (upper or lower extremity) of the musculoskeletal system tumor, the marital status of the patient, and the presence or absence of knowledge of the patient about the diagnosis (p>0.05). Educational status was the only factor that was found to be in correlation with the depression level (p<0.05). CONCLUSION: Lack of correlation between sociodemographic characteristics and the psychological status suggests that informing the patients with special attention to their physical and psychological integrity may contribute positively to the patients' psychiatric status.