Morphological and biomechanical effects of vitamin K2 on fracture healing: An animal study on the rat tibia fracture model.

OBJECTIVE: The aim of this study was to evaluate the effects of vitamin K2 on fracture healing. METHODS: Twenty-four 6-week-old male Wistar albino rats that had open tibia fractures induced were included in this study. They were divided into 2 groups of 12, a group that had vitamin K2 administered over 30 consecutive days and a control group. After 30 days, the rats were sacrificed, and from each group, 6 tibiae were selected for biomechanical testing to examine the mechanical strength of the callus tissue using the Instron 3-point bending test and 6 tibiae were selected for histological analysis to examine the density and organization of callus tissue using Allen's grading system and Huo et al's grading system. Furthermore, weekly x-rays were taken to evaluate bone union described by Lane and Sandhu, and osteocalcin, procollagen I N-terminal propeptide, and procollagen I C-terminal propeptide were examined in blood samples taken by intracardiac puncture during sacrification. RESULTS: Breaking force (P = .047), breaking time (P = .019), stiffness (P = .039), fracture strength (P = .041), and Young's modulus (P = .032) showed a statistically significant increase in the K2 group. Procollagen I C-terminal propeptide (P = .024), procollagen I N-terminal propeptide (.047), and osteocalcin (.048) levels were significantly higher in the K2 group compared to the control group. Furthermore, 3rd-week x-rays showed higher bone union scores according to the Lane and Sandhu method in the K2 group (P = .014). However, the histological grading systems of Allen and Huo et al did not show statistically significant differences between groups (P = .086, P = .07, respectively). CONCLUSION: In light of these findings, it could be concluded that vitamin K2 has a significant positive effect on fracture healing.

Bilateral non-traumatic hip fractures in a heavy smoker COPD patient on inhaled steroids.

INTRODUCTION: Bilateral proximal femoral fractures without trauma are very rare conditions. They have been reported in connection with osteoporosis, renal osteodystrophy, parathyroid disease, tumors, epileptic seizures, electroconvulsive therapy, and postirradiation. METHOD: We present a case of a 75-year-old man with bilateral hip fractures. No trauma, neurological, endocrinological disorder, or malignancy was reported in his history. He had a background of chronic obstructive pulmonary disease (COPD) and had been taking inhaled steroids (budesonide) 800 µg per day for 10 years. He was a heavy smoker with a smoking history of 120 packs/year. His complaints had initially started as pain on the left hip and groin and then had progressed to the right in 10 days. Plain x-rays of the pelvis showed left femoral neck and right subtrochanteric femoral fractures. Fixation with proximal femoral nail of the right hip and partial arthroplasty of the left hip was performed on the following day after his admission. Pathological examination revealed osteoporosis in bone samples from both hips. RESULT: COPD and osteoporosis have some common risk factors. Smoking, decreased exercise capacity, inhaled, or oral steroid therapy may increase osteoporosis and risk of bone fractures by decreasing bone mineral density. Non-traumatic femoral fractures may occur in patients on long-term inhaled steroid treatment for chronic airway diseases such as asthma and COPD. CONCLUSION: History of COPD with corticosteroid use may be used as a diagnostic tool to identify patients having osteoporosis. Preventive measures can be performed by monitoring high-risk patients with bone mineral densitometry, WHO fracture risk assessment tool (FRAX tool), serum calcium, and vitamin D levels to prevent bone fractures. Treating those patients with the lowest effective dose of corticosteroids should be targeted.

Comparison of intra-articular bupivacaine-morphine with bupivacaine-tenoxicam combinations on post-operative analgesia in patients with arthroscopic meniscectomy: a prospective, randomised study.

AIM: There are many alternatives for post-operative pain relief in patients who have had general anaesthesia. The aim of this study was to evaluate the efficacy of intra-articular bupivacaine + morphine and bupivacaine + tenoxicam applications in post-operative pain control in patients undergoing knee arthroscopy with general anaesthesia. METHOD: This was a prospective study. Standard anaesthesia procedures were applied to each patient, and the 240 patients chosen at random were then divided into two groups. Each group received a different combination of drugs for this double-blind study. The first group (group A: 120 patients) received 0.5% bupivacaine 100 mg + tenoxicam 20 mg (22 ml); the second group (group B) received 0.5% bupivacaine 100 mg + morphine 2 mg (22 ml); both groups received their drugs at the end of the intra-articular operation before tourniquet deflation. Before the operation, patients were asked about their post-operative pain at particular periods over the following 24 hours using the visual analogue scale (VAS) and the numeric rating scale (NRS). An additional analgaesic requirement and possible side effects were also recorded. RESULTS: Group A patients needed analgaesics sooner after operation than patients in group B. In Group B, VAS and NRS values were statistically higher compared with group A at the 12th hour. There were also fewer side effects seen in group A versus group B. CONCLUSION: Effective and reliable results were obtained in post-operative pain control in bupivacaine added to the morphine or tenoxicam groups following arthroscopic meniscectomy. In the tenoxicam group, patients reported less pain, fewer side effects and less need for analgesics at 12 hours after the operation. LEVEL OF EVIDENCE: level 1, therapeutic, randomised, multicentric study.

Short-term results of surgical treatment with cephalomedullary nails for basicervical proximal femoral fractures.

The treatment of basicervical femoral fractures remains controversial. The aim of this study was to examine the efficacy of intramedullary nail use in the surgical treatment of basicervical fractures. In total, 28 patients with basicervical fractures treated with proximal femoral nails were examined retrospectively. Fracture healing was observed in all patients, who were followed at least for 6 months. While the average radiological fracture healing timing was ~10.5 (8-14) weeks, clinical fracture healing occurred in 6 (5-9) weeks on average. Screw cut­out, avascular necrosis, femur fracture, and surgical wound infections did not occur in any patient. Severe collapse (>10%) was not noted in any patient. The postoperative mean Harris hip score was 81.2±21.3. Osteosynthesis application with a proximal femoral nail in basicervical proximal femur fractures is a surgical treatment that can be performed with minimally invasive techniques without open surgery. This is a rapid, sound, and simple treatment method with low morbidity.

[Long-term use of fondaparinux in major orthopedic surgery]. / Fondaparinuksun majör ortopedik cerrahide uzun süreli kullanimi.

OBJECTIVES: This study aims to investigate whether the usage of fondaparinux sodium may result in major hemorrhages following major orthopedic surgery. PATIENTS AND METHODS: Forty-three patients (30 females and 13 males; mean age 66 years; range 34 to 94 years) at the age of >18 years who were scheduled for major orthopedic surgery were included. Total hip arthroplasty, total knee arthroplasty and proximal femur fracture surgeries were defined as the major orthopedic surgeries. Prophylaxis was administered with 2.5 mg fondaparinux sodium once daily subcutaneously. Prophylaxis was initiated at 6-8 hours after the closure of incision. During the prophylaxis period (31±3 days), the patients were monitored for symptomatic deep venous thrombosis. Serum creatinine, platelet and hemoglobin levels were measured at the baseline and in the first week and at one month postoperatively. Wound healing time, healing complications, and major/minor hemorrhages seen during the prophylaxis period were recorded. RESULTS: During the follow-up, none of the patients had symptomatic deep vein thrombosis or symptomatic pulmonary embolism. Two patients (4.6%) had delayed wound healing, while four (9.3%) had minor ecchymosis. No major hemorrhages were observed in any patients. CONCLUSION: With the long-term use of fondaparinux, we did not observe any major hemorrhagic complications. However, further large-scale studies including control groups are required to establish the effects of long-term use of fondaparinux.

Reduction and fixation of radius neck fractures in children with intramedullary pin.

In radius neck fractures, reduction manipulations applied on the radial head with percutaneous K-wires may lead to epiphysis or physis damage. In this study, 16 cases were evaluated without using any percutaneous manipulations upon the displaced radius head. Rather, an Ender-pin-like, curve-tipped K-wire was inserted intramedullary (Metaizeau technique) after a certain amount of reduction by manual manipulation under fluoroscopic guidance. Complete reduction was obtained with wire rotations in 16 patients. A total of 16 patients with open growth plates with an average age of 8 years were enrolled within the scope of the study. Thirteen patients (81.25%) showed excellent clinical results, two patients (12.5%) showed good results, and one patient (6.25%) showed average results. None of the cases exhibited poor results. A single K-wire was used in nine cases, whereas two K-wires were used for fixation rigidity in seven cases with larger medullas. No sign of neurovascular deficit, synostosis, or infection was observed in any of the cases. In conclusion, the use of two wires in patients with larger medullas and emphasis on the importance of closed reduction, even without percutaneous K-wire manipulation, might lead to the development of a new treatment approach for pediatric patients with radial head fractures.

Ipsilateral femoral shaft and vertical patella fracture: a case report.

INTRODUCTION: A femoral shaft fracture with an ipsilateral patella fracture has been, to our knowledge, given only cursory attention in English-speaking literature. CASE PRESENTATION: A 15 year old male patient had hitten by a car to his motorcycle came to emergency room and he had been operated for his femoral shaft freacture and vertical patellar fracture which was iniatally missed. CONCLUSION: To us it is vital to obtain CT scan of the patient's knee if there is an ipsilateral femoral fracture with an ipsilateral knee effusion and a punction which reveals hematoma even in the absence of a fracture line seen in AP and lateral projections.

Distal tibial epiphyseal fracture (Tillaux) and capsular interposition.

Arthroscopic-assisted reduction is one recommended technique for pediatric distal tibial epiphyseal fractures. A 15-year-old male patient with a triplane distal tibial epiphyseal fracture (Tillaux type) was scheduled for arthroscopic reduction and pinning, which failed to provide adequate fracture reduction. Open surgery was subsequently performed, which revealed a capsular interposition in the fracture line attributable to an anterior capsular tear of the ankle. The possibility of capsular interposition should always be taken into consideration when problems such as those described in this case presentation are encountered in such patients. This is precisely why direct visualization either through arthroscopy or open arthrotomy is sometimes necessary.

Bilateral simultaneous traumatic hip dislocation in opposite directions: a case report.

Bilateral traumatic hip dislocation is rarely seen. A patient who presented with simultaneous dislocation of both hips in opposite directions is presented in this case report. A 42-year-old female patient who was injured in a motor vehicle accident as a passenger was brought to the emergency department and was diagnosed with posterior fracture dislocation of the right hip and anterior dislocation of the left hip. Both hips were reduced under general anaesthesia by closed manipulation, and reduction was confirmed with computerized tomography. No skeletal or skin traction was applied. Hip range of motion exercises were begun immediately. The patient was mobilized at the end of the sixth week and returned to daily activities without any complaint at the end of 16th week.

Surgical treatment for calcaneal intraosseous lipomas.

Intraosseous lipoma is among rare benign tumors of the bone. The aim of the present study was to evaluate the long-term surgical results of calcaneal lipomas, representing a relatively rare localization for this type of tumors. The present study included 21 calcaneal lipoma cases (22 feet) referred to our podiatry clinic between 1991 and 2001 with complaints of foot and heel pain resistant to conservative treatment for the last 3-6 months. In all cases, the diagnosis of calcaneal intraosseous lipoma was first confirmed radiologically, then histologically. The mean age was 39 years (range 16-62), 15 were females (71%) and 6 were males (29%). One patient had bilateral disease, whereas 11 and 9 patients had right and left calcaneal involvement, respectively. None of the patients have a palpable mass in their foot. For pre-operative differential diagnosis, 3 patients had computerized tomography examination (CT scan) and 8 patients underwent magnetic resonance imaging (MRI). All lesions were totally curetted out with angled curettes. The defect was filled with cancellous autografts taken from the ipsilateral iliac crest. In only four patients, the amount of autograft was not sufficient, so a combination of cancellous allograft and autograft was used. No drain was used. An elastic bandage was wrapped around the foot and ankle, and cold packs were applied to the surgical site. The mean duration of follow up was 94 (45-143) months. Pain improved in 17 feet at 4 months, in an additional 4 feet at 8 months and in the remaining one foot at 12 months. The mean time to the graft consolidation was 5 months (range 3-7 months). There were no recurrences or pathological fractures during the follow up. No wound infection or necrosis was seen at the surgical sites. There were no neurovascular complications. Five cases experienced pain in the iliac bone for 1 month, due to grafting procedures. Although calcaneal intraosseous lipoma accounts for a small portion of cases in the huge differential diagnosis chart for foot pain, it should be kept in mind as a possible diagnosis in unresolved cases. Most of the patients would benefit from non-surgical treatments. But if this is not the case, surgical treatment is indicated. In conclusion, curettage and autogenous bone grafting is an easy and effective method for the surgical treatment of calcaneal intraosseous lipomas.

Simultaneous ipsilateral proximal interphalangeal and metacarpophalangeal dislocation of the fifth phalanx: A case report.

INTRODUCTION: There is no case of simultaneous ipsilateral proximal interphalangeal and metacarpophalangeal dislocation of a finger in the literature. CASE PRESENTATION: A 61 years old male patient sustained an ipsilateral dorsal dislocation of the PIP joint of his fifth finger and dorsal dislocation of the metacarpophalangeal joint. Closed reduction of proximal interphalangeal joint was achieved while open reduction of the metacarpophalangeal joint was carried out. CONCLUSION: The single most important element preventing reduction of the metacarpophalangeal joint was an interposition of the volar plate between proximal end of the phalanx and the head of the metacarpal.

Intraoperative dislocation of the prosthetic femoral head into the pelvis during total hip arthroplasty.

An 86-year-old woman with severe osteoarthritis and severe pain in her left hip underwent total hip arthroplasty. Intraoperatively, the 22 mm femoral head impinged on the anterior rim of the acetabulum during a reduction maneuver, and disengagement of the femoral head from the neck occurred with migration of the head over the pelvic brim along the inner table of the pelvis. This complication related with hip arthroplasty is underestimated by many orthopaedic surgeons.

Lateral dislocation of the knee joint after total knee arthroplasty: a case report.

BACKGROUND: Total knee arthroplasty (TKA) is a successful therapy for functional improvement and pain relief in advanced symptomatic degeneration of the knee joint. But it can be associated with many complications, one of which is instability. CASE PRESENTATION: A 70-year-old woman was referred to our hospital because of right knee dislocation after TKA was performed on her right knee due to severe varus deformity and flexion contracture. This instability was caused by persistent MCL tightness and iatrogenic lateral collateral, arcuate ligament, and popliteus tendon injury.The torn lateral collateral ligament and arcuate ligament were sutured with no. 2 non-absorbable (Ethibond) sutures with plication of the posterolateral knee capsule. A deep-dish liner was inserted to optimize soft tissue tension. CONCLUSION: This is a very severe complication, and surgeons must be cautious about ligament balancing and soft tissue resection during TKA for severe varus and valgus deformities.

Pyomyositis of tensor fascia lata: a case report.

INTRODUCTION: Pyomyositis is a disease in which an abscess is formed deep within large striated muscles. CASE PRESENTATION: We report the case of a 10-year-old boy who presented with fever and a painful hip and was subsequently diagnosed with pyomyositis of the tensor fascia lata. In children with clinical and laboratory findings of inflammation in the vicinity of the hip joint, the differential diagnosis includes transient synovitis, an early stage of Legg-Calvé-Perthes disease, infectious arthritis of the hip, rheumatologic diseases and extracapsular infection such as osteomyelitis. CONCLUSION: To the best of the authors' knowledge, this is the first report of pyomyositis of the tensor fascia lata. Although pyomyositis is a rare disease and the differential diagnosis includes a variety of other commonly observed diseases, pyomyositis should be considered in cases where children present with fever, leukocytosis and localized pain.

Fractures of the bilateral distal radius and scaphoid: a case report.

INTRODUCTION: Bilateral fractures of the distal radius and scaphoid are extremely rare injuries. CASE PRESENTATION: A patient with bilateral comminuted, displaced distal fractures of the radius and bilateral fractures of the scaphoid was treated via internal fixation of the scaphoid fractures with Herbert screws and internal fixation of the distal radius fractures with locked volar plating. CONCLUSION: Rigid internal fixation of distal radius and scaphoid fractures is mandatory to start early active rehabilitation of the wrist without the need for wrist immobilization with a plaster or external skeletal fixation.

Chondroprotective effect of salicylate and chloroquine in pyogenic septic arthritis.

INTRODUCTION: This study aims to investigate the effectiveness of salicylate (Aspisol; Bayer AG, Leverkusen, Germany) and chloroquine on preventing cartilage damage in septic arthritis. METHODS: A septic arthritis model was created by inoculating the knee joint of young rabbits (n=21) with Staphylococcus aureus. Some rabbits with inflicted septic arthritis did not undergo any treatment and served as the control group (n=7). The second group (n=7) was started on salicylate on day 2 to investigate the effects of salicylate on joint cartilage. The third group (n=7) was started on chloroquine on day 2 to investigate the effects of chloroquine on joint cartilage. All three groups underwent arthrotomy, drainage and synoviectomy on day 7 of the experiment. Animals were sacrificed on day 14 and the joint cartilages were extracted. Histopathology, determination of local prostaglandin (PGE)-like activity, and evaluation of hyaluronic acid loss were performed on all samples. RESULTS: The control group and the salicylate group were similar in the extent of joint damage. Salicylate did not prevent joint cartilage damage despite inhibiting PGE synthesis. Chloroquine, despite not inhibiting PGE synthesis, did prevent cartilage destruction. CONCLUSION: If supported by larger-scale studies, chloroquine could be added to the antibiotic regimen in the treatment of septic arthritis to prevent cartilage damage.

Early tunnel enlargement after arthroscopic ACL reconstructions.

The aim of this study was to evaluate the tunnel enlargement phenomenon after ACL reconstructions performed with hamstrings tendons fixed using the cross pin technique. Sixty-two knees in 62 patients were followed for two years to evaluate the possible clinical implications of the femoral and tibial tunnel enlargements noted after ACL reconstruction. The reconstructions were done with hamstring tendons using the cross-pin technique. Evaluation was based on calculated clinical scores (IKDC and Lysholm knee scores) and quantified by KT-1000 measurements. Sagittal and coronal plane computed tomography and conventional radiography were performed 3 days after operation and were repeated after 3 and 6 weeks, 6, 12 and 24 months, to assess early tunnel enlargement. Although it seems that tunnel enlargement after ACL reconstruction has no impact on the clinical results, long-term implications and potential need for revision surgery must be assessed. In this study, tunnel enlargement was noted fairly early after operation and was thought to be related with drilling of the tunnels. A possible solution to this problem may be drilling the tunnels to a diameter 1 mm smaller than the measured graft diameter, then to enlarge the tunnels to the graft diameter with the appropriate tunnel dilator.

[Osteotomies for acetabular dysplasia in adults and adolescents]. / Eriskin ve ergenlik dönemlerinde asetabuler displazi için yapilan osteotomiler.

The aims of treatment for acetabular dysplasia are the normalization of the relationship between the femoral head and acetabulum on weight bearing position, and to provide a painless, stable, and functional hip in the long-term. The reason of this abnormal relationship may arise either from the acetabulum (deficiency, maldirection) or the femoral head (aspheric, subluxation, valgus, varus). For this reason, preoperative planning, assessment, and patient selection are very important. Acetabular dysplasia is the main reason for hip osteoarthritis. Overcorrection is an important complication of acetabular osteotomies. This review summarizes different kinds of acetabular osteotomies with relevant presentation of our technique.