The effect of eccentric glenoid reaming in reverse shoulder artrhoplasty for glenohumeral osteoarthritis.

Background: The objective of this study was to evaluate the abilitiy of eccentric reaming in reverse total shoulder arthroplasty (RSA), in patients with glenohumeral osteoarthritis (GHOA), to correct preoperative glenoid retroversion and to compare with cuff tear arthopaty (CTA) cases. Methods: Fifty-nine patients who underwent RSA with GHOA or CTA diagnosis between 2013 and 2022 and who had pre- and postoperative computed tomography scans were included in the study. Preoperative glenoid version and postoperative glenoid component versions of 17 patients with GHOA and 40 patients with CTA were measured by Friedman method. Results: The median preoperative glenoid versions in GHOA and CTA groups were measured as 16° and 4° retroverted respectively (p < 0.01). The median postoperative glenoid component versions in GHOA and CTA groups were 5° and 3° retroverted respectively (p = 0.09). The version change differences between the two groups varied significantly (p < 0.01). Conclusions: GHOA is related with higher preoperative glenoid retroversion compared to CTA. However; with eccentric glenoid reaming, adequate version correction and similar postoperative glenoid version can be achieved in GHOA compared to CTA when performing a RSA. Level of evidence: Level III. Retrospective study. Treatment study.

Does previous arthroscopic Bankart repair influence coracoid graft osteolysis in Latarjet procedure? A case-control study with computed tomography scan data.

BACKGROUND: The Latarjet procedure is commonly performed in the treatment of recurrent shoulder instability and is also indicated as a salvage procedure for recurrence after failed arthroscopic Bankart repair. Although this procedure has shown success, there has been an increased awareness of complications in recent studies, especially graft osteolysis. Most relevant research has focused on the pathophysiology, incidence, or location of graft osteolysis or the risk factors for graft osteolysis; however, the data are limited to primary Latarjet procedures. This study aimed to investigate the effect of previous arthroscopic Bankart repair surgery on coracoid bone graft osteolysis in the Latarjet procedure. METHODS: This retrospective case-control study analyzed data from patients who underwent primary Latarjet procedures or revision Latarjet procedures following failed arthroscopic Bankart repair. Clinical outcome measures included range of motion, the Subjective Shoulder Value, and the Rowe score. Volumetric analysis of each transferred coracoid graft was performed using early postoperative and late postoperative computed tomography scan data, and the amount of graft osteolysis was then calculated as the percentage of volume reduction of each graft. RESULTS: A total of 32 patients who met the inclusion criteria were included in this study, with 24 patients in the primary Latarjet group (group I) and 8 patients in the revision Latarjet group (group II). The mean age of the patients was 32.5 ± 7.7 years, and the mean follow-up duration was 52.1 ± 8.9 months. Both study groups showed significant improvement in the Subjective Shoulder Value compared with baseline (P < .05). Comparison of postoperative clinical outcome measures showed no significant difference in any outcome parameter between the 2 study groups (P > .05). No recurrence was observed during the follow-up period. A positive apprehension sign was present in 6 patients (25%) in group I and 4 patients (50%) in group II (P > .05). Analysis of radiologic data revealed that all patients underwent some degree of graft osteolysis, with varying osteolysis ratios between 12% and 98%. The mean osteolysis ratio of the coracoid graft was 67.3% ± 22.6% in group I and 69.4% ± 25.6% in group II, with no significant difference between the 2 groups (P > .05). CONCLUSION: The findings of this study suggest that a considerable amount of coracoid graft osteolysis is observed after both primary Latarjet procedures and revision Latarjet procedures following failed arthroscopic Bankart repair. Previous arthroscopic Bankart repair did not seem to have a significant influence on the amount of graft osteolysis, and both primary and revision Latarjet procedures showed satisfactory clinical outcomes.

Long-Term Evaluation of Ulnar Nerve Function in Patients with Distal Humerus Fractures Treated with Open Reduction and Internal Fixation: A Nerve Conduction Study.

OBJECTIVES: To investigate the long-term evaluation with electromyography of ulnar nerve function in patients with distal humerus fractures (DHFs) treated with open reduction and internal fixation. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENTS: Fifty-two patients (20 men and 32 women) with DHFs. INTERVENTIONS: All patients underwent open reduction and internal fixation between 2002 and 2017 with a minimum five years' follow-up. MAIN OUTCOME MEASUREMENTS: The nerve conduction test was done for evaluation ulnar nerve function. Secondary outcomes were modified McGowan grading system for symptoms of ulnar neuropathy. RESULTS: The mean follow-up time was 112.7 ± 39 months after surgery. 28.8% (15) of the patients scored in Grade I, 30 (57.6%) in Grade II, and 7 (13.6%) in Grade III on the affected side according to McGowan grading scale. According to EMG results, 40.1% (21/52) of patients had abnormal results. There was significant difference between fracture and unaffected side regarding ulnar nerve motor wrist CMAP amplitude, motor below elbow CMAP amplitude, above elbow CMAP amplitude, above elbow MNCV, and sensory wrist amplitude. Ulnar nerve motor wrist-ADM latency (p = 0.01; r = 0.446) and ulnar nerve sensory conduction velocity (p < 0.001, r = -0.504) were significant correlation with McGowan grading scale. CONCLUSION: There were significant difference ulnar nerve motor amplitude and sensory wrist amplitude between fracture and unaffected side. A mean decrease in sensory amplitude of fracture elbow was found 25% compared to the unaffected side in our result. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic superior capsular reconstruction versus reverse shoulder arthroplasty in patients with massive irreparable rotator cuff tears: A comparative clinical study.

OBJECTIVE: This study aimed to compare the clinical and functional outcomes of reverse shoulder arthroplasty versus arthroscopic supe- rior capsular reconstruction in the treatment of patients with massive irreparable rotator cuff tears and Hamada grade 1-2 glenohumeral arthritis. METHODS: It is a retrospective case-control study comparing the prospective results of 2 different treatment methods. This retrospective comparison of groups was conducted between May 2016 and May 2020. The study included 40 people with massive irreparable rotator cuff tear and Hamada grade 1-2 arthropathy who had arthroscopic superior capsular reconstruction with tensor fascia latae autograft or reverse shoulder arthroplasty surgery. Patients were divided into 2 groups according to treatment. Clinical outcome measures included shoulder range of motion, pain, and functional scores (Constant-Murley, American Shoulder and Elbow Surgeons). RESULTS: The mean age was 61.85 ± 7.56 and 71.10 ± 6.42 years, respectively, for group I [superior capsular reconstruction (n=20)] and group II [superior capsular reconstruction (n=20)]. The mean follow-up was 22.30 ± 8.4 and 32.50 ± 8.11 months, respectively. In the postoperative data, flexion degrees and Constant scores were significantly higher in the superior capsular reconstruction group (P=.007, P = .043). No significant difference was found between the 2 groups in all parameters (P > .05) except abduction. The increase in abduction value in the reverse shoulder arthroplasty group was significantly higher than in the superior capsular reconstruction group (P = .003). In addition, postoperative data in all parameters in both groups showed significant changes compared to preoperatively. CONCLUSION: This study has shown that superior capsular reconstruction with tensor fascia latae autograft can provide clinical and func- tional improvement similar to the reverse shoulder arthroplasty procedure in treating massive irreparable rotator cuff tears with Hamada grade 1-2 arthropathy. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

Gender and degree of tendon healing are independent predictive factors for clinical outcome in successfully healed rotator cuff tears.

PURPOSE: Arthroscopic rotator cuff repair (aRCR) is a commonly performed procedure and has been reported to be a successful treatment. Successful healing has traditionally been considered to be associated with good outcome; however, knowledge on predictive factors affecting final outcome other than tendon healing is limited. This study aims to investigate predictive factors influencing clinical outcome following aRCR in patients with successfully healed tears. METHODS: This retrospective case-control study was conducted in a single center with 135 patients who had successfully healed tendons based on Sugaya classification (grades I-III) on postoperative magnetic resonance imaging (MRI) scans following aRCR. Clinical outcome measures included Constant-Murley score (CMS), range of motion (ROM), pain score. Various preoperative, intraoperative factors and degree of postoperative tendon healing were assessed to identify independent predictive factors for final clinical outcome. RESULTS: Mean age of patients was 55.9 ± 9.0 years and mean follow-up duration was 46.8 ± 14.9 months. There were 50 (37%) male and 85 (63.0%) female patients. At final follow-up, mean CMS was 85.7 ± 12.0. Considering mean postoperative CMS and the minimal clinically important difference (MCID) of 10 points for CMS, a cutoff level of 75 points for CMS was set (85-10 = 75) and study population was divided into two study groups (group I, poor outcome, CMS ≤ ;75, and group II, good outcome, CMS > 75). There were 24 (17.8%) patients in group I and 111 (82.2%) patients in group II. Univariate analysis revealed that gender, body mass index (BMI) and degree of tendon healing (Sugaya classification) differed significantly between two groups (p < 0.05). Multivariate logistic regression analysis which was conducted with these variables showed that female gender (odds ratio 3.65) and Sugaya grade III (odds ratio 8.19) were independent predictive factors which were significantly associated with poor outcome (p < 0.05). CONCLUSIONS: This study showed that despite achieving a successful healing, considerable amount of patients (17.8%) have ended up with poor outcome. Female gender and degree of tendon healing were identified as independent predictive factors for poor outcome. These data would help surgeons during decision-making, risk assessment and patient counseling. LEVEL OF EVIDENCE: III.

FIXATION METHODS IN LATARJET: BIOMECHANICAL COMPARISON OF SCREW TYPES AND PLATE FIXATION.

Objective: Latarjet procedure is often preferred in recurrent shoulder dislocations accompanied by glenoid bone loss. It is observed that the superiority of bone graft fixation methods is still controversial. The aim of this study is to biomechanically compare the bone graft fixation methods in the Latarjet procedure. Methods: 15 third-generation scapula bone models were divided into 3 groups. Graft was fixated in the first group with fully-threaded cortical screws of 3.5mm diameter, in the second group two 16 mm partially-threaded cannulated screws of 4.5mm diameter, and in the third group via a mini plate and screw. The hemispherical humeral head was placed on the tip of the cyclic charge device, and thus, the charge applied to the coracoid graft was homogeneous. Results: No statistically significant difference was found between paired comparisons (p>0.05). The forces in 5 mm displacement in total vary between 502-857N. Total stiffness measurements ranged between 105 and 625; the mean value was 258.13±53.54 with no statistically significant difference by groups (p = 0.958). Conclusion: This biomechanical study showed that there is no difference between three coracoid fixation options in terms of fixation strength. Unlike previous assumptions, plate fixation is not biomechanically superior to screw fixation. Surgeons should consider their personal preferences and experience in choosing fixation methods.

Objetivo: O procedimento Latarjet é normalmente preferencial em deslocamentos recorrentes do ombro acompanhados por perda óssea da glenóide. Observa-se que a superioridade dos métodos de fixação dos enxertos ósseos ainda é controversa. O objetivo deste estudo é comparar biomecanicamente os métodos de fixação de enxerto ósseo no procedimento Latarjet. Métodos: 15 modelos de escápulas de terceira geração foram divididos em 3 grupos. O enxerto foi fixado no primeiro grupo com parafusos corticais totalmente rosqueados com 3,5 mm de diâmetro, no segundo grupo com dois parafusos canulados parcialmente rosqueados de 16 mm de diâmetro de 4,5 mm e no terceiro grupo através de miniplaca e parafuso. A cabeça hemisférica umeral foi colocada na ponta do dispositivo de carga cíclica e, desta forma, a carga aplicada ao enxerto coracoide foi homogênea. Resultados: Nenhuma diferença estatisticamente significativa foi encontrada entre as comparações pareadas (p>0,05). As forças em 5 mm de deslocamento no total variam entre 502-857N. As medidas de rigidez total variaram entre 105 e 625 e o valor médio foi 258,13±53,54, sem diferença estatisticamente significativa por grupos (p = 0,958). Conclusão: Este estudo biomecânico mostrou que não há diferença entre três opções de fixação de coracoides em termos de resistência à fixação. Ao contrário de suposições anteriores, a fixação de placas não é biomecanicamente superior à fixação de parafusos. Os cirurgiões devem considerar suas preferências pessoais e sua experiência na escolha de métodos de fixação.

Clinical and anatomical outcomes of isolated coracoclavicular fixation after acromioclavicular joint injury: is it stable enough or is additional horizontal fixation necessary?

Background: Recently, an emphasis has been put on anatomical reduction of acromioclavicular (AC) joint both in vertical and hortizontal planes for management of AC joint injuries due to persisting horizontal instability. Therefore, an additional AC fixation in horizontal plane has been recommended. However, relation between horizontal AC joint instability and clinical outcomes is still controversial. This study aims to evaluate outcomes of isolated coraco-clavicular fixation using arthroscopic assisted single coraco-clavicular tunnel technique in grade III and V AC joint injuries and to investigate the correlation between anatomical and clinical outcomes. Methods: This study was conducted with 19 patients with grade III or V AC joint injury. Clinical outcomes included postoperative pain intensity and functional outcomes (Constant Score, American Shoulder and Elbow Surgeons, and Subjective Shoulder Value). Radiological evaluations were performed using radiographs and postoperative computed tomography scans. Degree of initial injury and postoperative stability both on axial and coronal planes were evaluated after radiological assessment. Correlations between anatomical and clinical outcomes were investigated using Pearson's correlation test. Results: At the final follow-up assessment, the mean pain score was 1.8 ± 1.8, mean American Shoulder and Elbow Surgeons score was 81.0 ± 15.4, mean Subjective Shoulder Value was 81.3 ± 19.6, and mean Constant Score was 86.3 ± 14.8. The mean loosening ratio and AC distance were 43.5 ± 30.6% and 4.3 ± 12.4 mm, respectively. No correlation was observed between postoperative anatomical and clinical outcomes (P > .05). Conclusion: Additional AC fixation on horizontal plane is not a prerequisite for all injuries, there is no significant association between horizontal instability and clinical outcomes and indications of an additional AC fixation needs to be determined.

Older age and higher body mass index are independent risk factors for tendon healing in small- to medium-sized rotator cuff tears.

PURPOSE: Many previous research efforts have been made to identify prognostic factors for rotator cuff healing. However, majority of these studies were conducted with heterogeneous cohorts consisted of different tear characteristics. Healing properties of a rotator cuff tear may differ depending on tear characteristics such as tear size or fatty infiltration. Therefore, studies with subgroups confined by these variables may reflect more accurate results. This study aims to investigate predictive factors for rotator cuff healing in a subgroup with small- to medium-sized tears without significant fatty infiltration. METHODS: This retrospective case-control study was conducted with 94 patients with small- to medium-sized rotator cuff tears. Mean age of patients was 56.0 ± 9.0 years and mean follow-up duration was 38.3 ± 8.1 months. Post-operative magnetic resonance imaging assessment showed that there were 75 (79.8%) successfully healed repairs and 19 (20.2%) healing failures. Age, gender, hand dominancy, body mass index (BMI), smoking habit, diabetes, corticosteroid injection, baseline clinical status, duration of surgery and biceps procedure were variables evaluated as predictive factors. RESULTS: Both study groups showed significant improvement from baseline regarding clinical outcome measures (p < 0.05). However, successfully healed patients had significantly higher post-operative functional scores and lower pain scores (p < 0.05). The univariate analysis revealed that healing was significantly affected by age (p = 0.004), BMI (p = 0.01) and diabetes (p = 0.03). In the multivariate analysis, age (p = 0.02) and BMI (p = 0.02) were found to be significant independent factors for healing. Cutoff values for oldest age and highest BMI were 63 years and 28.1 kg/m2, respectively, for a successful healing according to receiver-operating characteristic curve analysis. CONCLUSION: Healing failure after rotator cuff repair in small- to medium-sized tears is associated with poorer outcomes. Age and BMI are independent predictive factors for healing. A successful repair is more likely in patients younger than 63 years and with BMI less than 28.1 kg/m2. Surgeons should consider this information during risk assessment, decision making and patient counselling. LEVEL OF EVIDENCE: Level III.

Multidirectional instability of the shoulder: surgical techniques and clinical outcome.

Multidirectional instability of the shoulder has a complex pathoanatomy. It is characterized by a redundant glenohumeral capsule and increased joint volume. Subtle clinical presentation, unclear trauma history and multifactorial etiology poseses a great challenge for orthopedic surgeons in terms of diagnosis. Generally accepted therapeutic approach is conservative and the majority of patients achieve good results with rehabilitation. In patients who are symptomatic despite appropriate rehabilitation, surgical intervention may be considered. Good results have been obtained with open inferior capsular surgery, which has historically been performed in these patients. In recent years, advanced arthroscopic techniques have taken place in this field, and similar results compared to open surgery have been obtained with the less-invasive arthroscopic capsular plication procedure.

Is coracoclavicular ossification a complication or a good prognostic factor after surgical treatment of acromioclavicular joint injury?

Background: The purpose of this study was to investigate whether heterotopic ossification (HO) in the coracoclavicular (CC) space after surgical treatment of acromioclavicular joint (ACJ) injury is a complication or a sign of good prognosis. Methods: Fifty-nine consecutive patients who underwent CC reconstruction with or without augmentation of the ACJ for acute ACJ injuries were analyzed. Postoperative American Shoulder and Elbow Surgeons (ASES) score, Constant score (CS), subjective shoulder value (SSV), and visual analog scale (VAS) results were evaluated. For radiological evaluation, HO was evaluated, and CC distances were measured. Results: Fifty-one patients (11 women and 40 men; mean age, 36 years [range, 17-68 years]) were evaluated after a mean follow-up of 3 years (range, 2-8 years). The mean ASES score at the follow-up was 82.73 (range, 51.6-100), mean CS was 85 (range, 50-100), mean SSV was 80 (range, 40-100), and mean VAS was 1.9 (range, 0-5). It was observed that the clinical outcomes (ASES, CS, SSV, VAS) of patients who developed ossification in the CC space were better than those who did not although it was not statistically significant. No statistically significant differences were found in the clinical outcomes (ASES, CS, SSV, VAS) between patients who underwent CC reconstruction without augmentation of the ACJ and those who were combined (P > .05). Conclusion: HO in the CC space is a common finding following AC joint fixation injury. We suggest that HO is not a complication and might possibly have positive effects on clinical outcomes.

Impact of different extraction processes on aflatoxin contamination in peanut oil.

Aflatoxins (AFs) are genotoxic carcinogens and are a growing concern in peanuts and peanut products. This study aims to impact of different extraction processes on the transition of AFs from peanuts to oils. Peanuts were collected from nine different factories in Osmaniye, Turkey, during the period of November 2017-May 2018. While no aflatoxin G1 (AFG1) and aflatoxin G2 (AFG2) were detected in peanuts, aflatoxin B1 (AFB1) and aflatoxin B2 (AFB2) were determined in all peanut samples at levels varying from 26.7 to 234.7 µg kg-1 and from 4.44 to 44.0 µg kg-1, respectively. No AFs were quantified in oils obtained by the industrial application method. The ratios of AFB1 transitions to oils obtained by solvent extraction, cold pressing of roasted peanuts and cold pressing methods were 9.0-79.8%, 11.3-75.3% and 9.3-77.6%, respectively. The concentrations of AFB2 in oils obtained by solvent extraction, cold pressing of roasted peanuts and cold pressing methods were 0.46-17.2 µg kg-1, 0.84-33.0 µg kg-1 and 1.02-36.3 µg kg-1, respectively. This is the first demonstration of the impact of different extraction processes on the transition of AFs from peanuts to oils.

Arthroscopic coracoclavicular button fixation versus anatomic locking plate fixation for unstable distal clavicular fractures.

HYPOTHESIS: Neer type II distal clavicle fractures are unstable and associated with high nonunion rates. The aim of this retrospective study was to compare the clinical and radiographic outcomes of anatomic locking plate fixation and arthroscopic coracoclavicular button fixation for unstable distal clavicle fractures. METHODS: Forty-seven patients with Neer type II distal clavicle fractures were treated surgically using either anatomic locking plate fixation (group 1, n = 20) or all arthroscopic coracoclavicular button fixation (group 2, n = 27) between 2012 and 2019 in 2 centers. Clinical and radiographic outcomes after an average follow-up period of 49 months for group 1 and 32 months for group 2 were assessed using the American Shoulder and Elbow Surgeons Shoulder score, Constant-Murley score, visual analog scale score and X-rays. RESULTS: At the final follow-up, the mean American Shoulder and Elbow Surgeons Shoulder score, Constant-Murley score, and visual analog scale score for group 1 and group 2 were 92.5 ± 3.9 (range 88.3-98.3), 93.6 ± 4.0 (range 90-100), and 0.6 ± 0.6 (range 0-2) and 95 ± 3.3 (range 86.6-100), 96.2 ± 3.0 (range 88-100), and 0.4 ± 0.5 (range 0-1), respectively (P = .32, P = .15, and P = .59, respectively). At the final follow-up, acceptable reduction and bone healing were achieved in all patients. All patients in both groups were able to resume work as well as sports activities. Postoperative complications included 1 case of acromioclavicular joint arthritis and 1 case of screw penetration in group 1 and 2 cases of coracoid process fracture that did not require additional surgery in group 2. Five patients underwent hardware removal owing to skin irritation and dissatisfaction with the cosmetic appearance in group 1. CONCLUSION: Both distal anatomic locking plate fixation and arthroscopic coracoclavicular button fixation provide satisfactory functional and radiological outcomes. Both procedures can be used to treat distal clavicle fractures because they have a minimal risk of complications and present similar, high union rates.

Repair Integrity and Functional Outcomes Between Knot-Tying and Knotless Suture-Bridge Arthroscopic Rotator Cuff Repair: A Prospective Randomized Clinical Trial.

BACKGROUND: Knot-tying suture-bridge (SB) rotator cuff repair may compromise the vascularity of the repaired tendon, causing tendon strangulation and medial repair failure. The knotless SB repair technique has been proposed to overcome this possibility and decrease retear rates. PURPOSE: To compare clinical and structural outcomes and retear patterns between the knot-tying and knotless SB techniques. We hypothesized that the knotless technique would result in lower retear rates owing to the preservation of intratendinous vascularity. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 104 patients with full-thickness rotator cuff tears were randomly and prospectively allocated to undergo knot-tying (group 1) or knotless (group 2) SB repair. Clinical outcome measures included range of motion, the visual analog scale (VAS) for pain, and the Constant score for function. Repair integrity was evaluated on magnetic resonance imaging scans using the Sugaya classification. Retears were also classified according to their pattern as type 1 (lateral) or type 2 (medial). RESULTS: Overall, 88 patients (group 1: n = 42 [mean ± SD age, 54.3 ± 9.8 years]; group 2: n = 46 [mean ± SD age, 55.8 ± 8.2 years]) were included in the final analysis. The mean ± SD follow-up period was 25.4 ± 8.3 and 23.3 ± 7.2 months for groups 1 and 2, respectively. From preoperatively to postoperatively, the mean VAS pain score improved significantly in both groups (group 1: from 7.4 ± 1.7 to 1.0 ± 1.7; group 2: from 7.1 ± 1.9 to 1.3 ± 2.0; P < .0001 for both), as did the mean ± SD Constant score (group 1: from 51.7 ± 13.4 to 86.0 ± 11.5; group 2: from 49.4 ± 18.4 to 87.2 ± 14.8; P < .0001 for both). There was no significant difference between the groups for the postoperative VAS or Constant score. The retear rate was not significantly different between the groups (19.0% [8/42] in group 1 and 28.3% [13/46] in group 2; P > .05). There was a significant difference in the type 2 failure rate (75.0% [6/8] in group 1 and 23.1% [3/13] in group 2; P = .03). CONCLUSION: Both techniques showed excellent improvement and comparable clinical outcomes, and there was no significant difference in retear rates. Consistent with previously published data, the type 2 failure rate was significantly higher with the knot-tying technique. REGISTRATION: NCT03982108 (ClinicalTrials.gov identifier).

The effect of oral magnesium supplementation on acute non-specific low back pain: Prospective randomized clinical trial.

OBJECTIVE: We aimed to investigate the effect of oral magnesium supplementation for acute low back pain. METHODS: This is a three-arm, prospective randomized open label clinical trial, which included two hundred and forty patients. We based our sample size calculation assumptions on a recently published clinical trial, thus we enrolled 80 patients for each group. NSAID alone group included (400 mg etodolac twice a day), NSAID + mg group included NSAID - magnesium combination treatment (400 mg etodolac twice a day with 365 mg oral magnesium supplementation) and NSAID + paracetamol group included NSAID - paracetamol combination treatment (400 mg etodolac twice a day with 500 mg paracetamol twice a day). Follow-up visits after initiation of relevant treatment were performed at 4th and 10th days and outcome measures included pain (Visual analogue scale - VAS), mobility of lumbar spine and functional outcome (RMDQ). RESULTS: Thirty-one patients were considered lost to follow-up or excluded due to use of other medications and final analysis was performed with 209 participants in three groups (71 patients in NSAID alone group, 68 patients in NSAID + mg group and 70 patients in NSAID + paracetamol group). NSAID + mg showed a significantly higher improvement in RMDQ and VAS scores at acute stage (at 4th day visit) compared to two other study groups However, there was no significant difference between three groups in terms of mean improvement of RMDQ, VAS scores and lumbar mobility between initial visit and 10-day. CONCLUSION: Results of this study suggest that addition of magnesium to acute low-back pain treatment does not significantly improve final clinical outcomes. LEVEL OF EVIDENCE: Level I, prospective randomized controlled study.

Technical Guide and Tips to Anterior Arthroscopic Latissimus Dorsi Transfer for Irreparable Subscapularis Tears.

In young patients, irreparable subscapularis tears can be managed by latissimus dorsi (LD) transfer on the lesser tuberosity. We provide a technical guide for isolated LD anterior transfer. The surgical procedure begins with glenohumeral exploration and release of the remaining subscapularis. Then, we dissect the LD tendon below the subscapularis. At the upper and inferior borders, we dissect the LD from the teres major, protecting the radial nerve anteriorly and inferiorly. Next, we detach the LD. Inferiorly, we cut the aponeurotic expansion for the triceps. A Foley catheter is used as a shuttle relay, anterior to the axillary nerve and medial and posterior to the radial nerve. We continue with an open dissection of the LD, posterior to the axillary fossa, to release the LD from the skin and tip of the scapula. The LD is transferred on the lesser tuberosity after retrieved by the Foley catheter, with care taken not to twist the tendon. It is fixed with 2 lateral anchors and 1 medial anchor. A shoulder brace is worn for 6 weeks. Physiotherapy begins thereafter.

Osteonecrosis of the talus of a child with acute lymphoblastic leukemia: A case report.

Osteonecrosis (ON) is a disabling complication of acute lymphoblastic leukemia (ALL) treatment in children and young adults. Isolated talus involvement is thought to be uncommon. A unique case of a 11-year-old female patient with ON in her left talus which developed six months after the completion of chemotherapy that she received for ALL is reported. A conservative treatment protocol was followed including activity modification, analgesia and prevention of weight-bearing. However, the disease significantly progressed during follow-up period. The present study makes an important contribution to the literature with unusual involvement pattern and location of ON after ALL treatment and with a long follow-up duration. LEVEL OF EVIDENCE: IV.

Functional outcomes of total knee arthroplasty in patients with Parkinson's disease: A case control study.

BACKGROUND: Parkinson's disease is a neurodegenerative condition causing coordination loss in musculoskeletal system. Many studies suggest that total knee arthroplasty in patients with Parkinson's disease has unfavorable treatment results and high complication rates. Our hypothesis was that total knee arthroplasty might be an effective procedure in patients with Parkinson's disease. METHODS: Parkinson's disease patients who underwent total knee arthroplasty between 2006 and 2018 were retrospectively evaluated. Patients who had Parkinson's disease diagnosis before surgery and who had a minimum follow-up duration of 12 months were included. Secondary knee osteoarthritis patients were excluded. A matched control group was randomly formed. Outcome measures were evaluated by preoperative and postoperative Knee Society Score and joint range of motion values. Comparison was made by means of increase in Knee Society Score and range of motion values. Study group patients were reviewed according to Columbia Classification System to determine disease severity. Stages I-II were accepted as "low-grade" and III-IV-V as "high-grade" disease. Another comparison was made between "low-grade" and "high-grade" patients. Patient who showed disease progression after surgery were also compared to patients without progression. RESULTS: There were 13 patients in both groups. In study group, mean preoperative and postoperative Knee Society Score values were 45.4 (±16.8) and 85.6 (±7.60); range of motion values were 93.9° (±17.0°) and 99.5° (±9.37°) respectively with a mean follow-up of 64.5 (±44.7) months. In control group, mean preoperative and postoperative Knee Society Score values were 38.8 (±11.5) and 86.1 (±10.0); range of motion values were 100.4° (±14.6°) and 109.2° (±10.2°) respectively with a mean follow-up of 51.8 (±13.6) months. No significant difference was observed between 2 groups (p > 0.05). Mean preoperative KSS and ROM values were significantly lower in high-grade patients (30.0 (±17.0) and 78.8° (±11.8°) respectively) compared to low-grade patients (52.2 (±11.9) and 100.6° (±14.7°) respectively) (p < 0.05). However, mean increase in KSS and ROM values were significantly higher for high-grade patients (p < 0.05). Mean increase in Knee Society Score and range of motion was 32.4 (±10.9) and 1.00° (±9.46°) respectively in patients with progression, 45.4 (±16.8) and 8.63° (±8.00°) in patients without progression (p > 0.05). CONCLUSION: Total knee arthroplasty is a successful treatment of knee osteoarthritis in Parkionson's disease patients with similar outcomes compared to general population despite disease severity and progression.

Atypical femoral fractures related to bisphosphonate use: A comprehensive review of 19 patients.

BACKGROUND: Atypical femur fracture is a rare complication of bisphosphonate treatment, which is widely used for the prevention of osteoporotic fractures. This study aims to report clinical and radiological features and outcomes of surgically treated atypical femur fractures related to bisphosphonates. METHODS: We retrospectively reviewed patients with the diagnosis of atypical femur fracture who were under bisphosphonate treatment and who were surgically treated in our clinic between January 2009 and December 2017. Patients who met the atypical femur fracture criteria defined by the American Society for Bone and Mineral Research were included in this study. Radiological features of the fractures, bisphosphonate treatment and duration, prodromal clinical and radiological findings were evaluated. Outcome measures included perioperative results, clinical and radiological outcomes and mobilization status. RESULTS: In this study, 19 patients were enrolled. Mean age of the patients was 69.6 years (range: 60.8-85.1) and the mean follow-up was 33.8 months (range: 13-104). Mean bisphosphonate use duration was 8.65 years (range: 3-18). Four patients had bilateral fractures. Eight of 23 fractures were subtrochanteric and 15 were diaphyseal. Twenty-one fractures were treated with an intramedullary nail, one fracture with a locked compression plate and one fracture with cephalomedullary nail. Union was observed in 15 fractures within the first six months. There was a delayed union in four fractures and non-union in four fractures. Mean union time was 5.1 months (range: 2-9). While seven patients preserved their preoperative mobilization status, 12 patients showed regression after the fracture. CONCLUSION: This study suggests that atypical femur fractures may have prodromal signs and that their management is complex due to high complication and nonunion rates.

Calcaneal Ewing's Sarcoma With Skip Metastases to Tarsals and Lymph Node Involvement: A Case Report.

Ewing's sarcoma (ES) represents the second most common primary malignant tumor of bone of children and occurs rarely in the bones of the foot. Dissemination to regional lymph nodes and skip metastases to adjacent bones are thought to be uncommon. We report a case of a 19-year-old female with the diagnosis of ES of the right calcaneus. Six months earlier, she had presented to the hospital with a history of ankle sprain and was treated with analgesics and ice application. Despite the treatment, the pain over the ankle persisted, her foot swelled progressively, and a mass evolved on the lateral side of the foot. She was referred to our clinic for further treatment options. Radiography and magnetic resonance imaging revealed an expansile mass originating from the calcaneus with talar and cuboidal skip metastases, with concomitant popliteal and inguinal lymph node involvement. The diagnosis was confirmed by histopathologic evaluation after Tru-Cut biopsy. Below-the-knee amputation with popliteal and inguinal lymph node dissection was performed after neoadjuvant chemotherapy. The postoperative first-year follow-up data for the patient showed no evidence of metastasis. The calcaneus is a rare location for the development of ES. A few patients with ES will present with skip metastases to adjacent juxtaarticular bones or regional lymph node involvement. Therefore, the present study has presented a unique case of ES with a rare anatomic location and an unusual metastatic pattern.

Prevalence of asymptomatic femoroacetabular impingement in Turkey; cross sectional study.

OBJECTIVES: Femoroacetabular impingement (FAI) is one of the causes of hip pain in young-adult patients. The purpose of our study is to determine the prevalence of radiological FAI findings in asymptomatic population in Turkey. METHODS: Trauma patients aged 18-65 years who applied to the emergency service between September 2015 and September 2016 were retrospectively evaluated for this study. After a preliminary study and power analysis, 2152 hips of the 1076 previously asymptomatic patients were evaluated radiologically with pelvis antero-posterior and frog-leg radiographs. On radiographs of these patients; alpha angle, lateral central edge angle (LCEA), Tönnis angle (TA) and collodiaphyseal angle were measured. Alpha angle values higher than 55° were noted as cam type FAI. TA values lower than 0° or LCEA values higher than 39° were noted as pincer type FAI. LCEA values lower than 25° or TA values higher than 10° were noted as acetabular dysplasia. RESULTS: Mean age of 1076 patients (602 female, 474 male) was 42.1 ±â€¯15.6 years. The assessment showed that 15.9% of the patients had cam type, 10.6% had pincer type, 3.1% had combined type FAI and 9.3% had findings of acetabular dysplasia. The prevalence of asymptomatic FAI is significantly more in males (46%) in comparison to females (17%) in Turkey. CONCLUSION: Even though FAI is considered to be a pathology associated with hip osteoarthritis; it is very common in asymptomatic population. In this respect, our study showed that prevalence of radiological FAI findings in asymptomatic adult population was 29.6% in Turkey.