Effects of tendon elongation on plantar pressure and clinical outcomes: A comparative analysis between open repair and minimally invasive surgery.

PURPOSE: The aim of this study was to assess whether variances in Achilles tendon elongation are linked to dissimilarities in the plantar pressure distribution following two different surgical approaches for an Achilles tendon rupture (ATR). METHODS: All patients who were treated with open or minimally invasive surgical repair (MIS) and were over 2 years post their ATR were eligible for inclusion. A total of 65 patients with an average age of 43 ± 11 years were included in the study. Thirty-five patients were treated with open repair, and 30 patients were treated with MIS. Clinical outcomes were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) and ATR Score (ATRS). Achilles tendon elongation was measured using axial and sagittal magnetic resonance imaging scans. Plantar pressure measurements for the forefoot, midfoot and hindfoot during gait were divided into percentages based on total pressure, measured in g/cm2 for each area. RESULTS: The average AOFAS score was found 'excellent' (93 ± 2.8) in the MIS group, while it was found 'good' (87.4 ± 5.6) in the open repair group. In addition, the MIS group showed significantly superior ATRS scores (78.8 ± 7.4) compared to the open repair group (56.4 ± 15.4) (p < 0.001). The average tendon elongation in the MIS group was 11.3 ± 2 mm, while it was 17.3 ± 4.3 mm (p < 0.001) in the open repair group. While the open repair group showed significantly higher plantar pressure distribution in the initial contact and preswing phases compared to uninjured extremities, there was no significant difference between the uninjured extremities and the MIS group. CONCLUSION: In conclusion, the findings of this study demonstrated that minimally invasive surgery was associated with less tendon elongation, more proximity to the plantar pressure distributions of the uninjured extremity and superior clinical outcomes compared to open surgical repair. Therefore, minimally invasive surgery may be considered a more suitable option for acute Achilles tendon repair to achieve overall better outcomes. LEVEL OF EVIDENCE: Level III.

Intramedullary Positive Tissue Culture Increases the Risk of Reinfection Following One-Stage Septic Revision Total Knee Arthroplasty.

BACKGROUND: Intraoperative acquisition of representative tissue samples is essential during revision arthroplasty of the infected total knee arthroplasty (TKA). While the number of intraoperative tissue samples needed to identify the organism is well described in the literature, there is still a paucity of evidence regarding the location of positive intraoperative samples and their correlation to postoperative outcomes. METHODS: There were forty-two patients who had septic failure following one-stage revision TKA for periprosthetic joint infection who were identified between January 2009 and December 2017. They were matched to a control group of patients who had successful one-stage revision TKA without septic failure. The location of positive intraoperative tissue samples was categorized as: 1) soft tissue; 2) interface between bone and prosthesis; and 3) intramedullary (IM). Chi-square, Student's t-, and Wilcoxon Mann-Whitney U-tests were used as appropriate. Univariate and multivariate logistic regression analyses were performed to evaluate predictors of septic failure. RESULTS: Weight > 100 kilograms (P = .033), higher Charlson Comorbidity Index (P < .001), and positive IM cultures (P < .001) were associated with a higher risk of reinfection after one-stage revision TKA. A positive IM sample carried a nearly five-fold increase in odds of reinfection (odds ratio 4.86, 95% confidence interval 1.85 to 12.78, P = .001). CONCLUSIONS: A positive IM culture sample is significantly associated with septic failure after one-stage exchange for periprosthetic joint infection of the knee. Patients who had positive IM cultures may benefit from longer postoperative antibiotic therapy for the treatment of one-stage exchange arthroplasty to minimize the risk of reinfection.

How Reliable Is the Absolute Synovial Polymorphonuclear Neutrophil Cell Count in Diagnosing Periprosthetic Joint Infection?

BACKGROUND: Diagnosing periprosthetic joint infection (PJI) is a daunting task for even the most experienced orthopedic surgeons, as there is currently no test available that can provide absolute accuracy. Utilizing an established synovial indicator for detecting PJI without incurring additional costs or resources would be the optimal solution for predicting the presence of infection. Therefore, we hypothesized that synovial absolute neutrophil count (ANC) would improve the diagnostic accuracy of chronic knee and hip PJI. METHODS: The study included 260 patients (134 men and 126 women, mean age of 70 years [range, 26 to 89]) who underwent aspiration during preoperative workup. Of these, 109 patients (41.9%) were diagnosed with chronic PJI (50 knees, 59 hips), and 151 patients (58.1%) were diagnosed as aseptic (94 knees, 57 hips). Data obtained from all patients included age, sex, procedure type (total hip or total knee arthroplasty), operation side, synovial white blood cell count (cells/µL), synovial polymorphonuclear cells percentage, and synovial α-defensin immunoassay value at the admission were retrieved from the electronic medical record. RESULTS: The calculated optimal threshold for synovial ANC of 1,415.5 cells/µL was associated with an area under the receiver operating characteristic curve (AUC) of 0.930 for chronic knee PJI diagnosis. The calculated optimal threshold for synovial ANC of 2,247 cells/µL was associated with an AUC of 0.905 for chronic hip PJI diagnosis. CONCLUSIONS: This study has conclusively shown that the synovial ANC serves as a valuable marker in the complicated diagnosis of PJI. This highly effective and efficient approach should be utilized for obtaining further information through standard tests, thereby ruling out the possibility of PJI. LEVEL OF EVIDENCE: III.

What is the diagnostic accuracy of neutrophil to lymphocyte ratio and monocyte to lymphocyte ratio in detecting acute periprosthetic joint infections? A gender-specific analysis.

PURPOSE: The accurate and timely diagnosis of periprosthetic joint infection (PJI) is critical for guiding optimal treatment management and success, highlighting the requirement of readily available inexpensive serum biomarkers to increase the diagnostic accuracy for PJI. Many studies have investigated the diagnostic accuracy of neutrophil to lymphocyte ratio (NLR) and monocyte to lymphocyte ratio (MLR). However, there is a lack of existing literature regarding optimal thresholds for acute PJI. The purpose of this study was to reveal the most appropriate cut-off values for MLR and NLR in detecting acute PJI with a gender specific analysis. METHODS: Patients were classified as having an acute PJI if they met the International Consensus Meeting (ICM) 2018 modified criteria. Patients who had a negative clinical and diagnostic workup for a PJI and the presence of erythema on the index surgical area were included in the erysipelas group (control group). Data obtained from all patients included age, sex, body mass index (BMI), Charlson Comorbidity Index (CCI), procedure type (THA or TKA), serum C-reactive protein (CRP), and blood studies at the admission and culture results were retrieved from the electronic medical record. RESULTS: ROC curve analysis was used to determine the gender-specific optimal threshold values for CRP, NLR, and MLR. Comparing the sensitivities and specificities of NLR and MLR at the identified best thresholds in males and females, the study found similar sensitivities of NLR in males and females with 0.84 and 0.84, respectively. On the other hand, an MLR of 0.67 or more reported a notably higher specificity in male patients [0.90 (95% CI 0.75-0.96) versus 0.70 (95% CI 0.56-0.80)]. CONCLUSION: NLR and MLR represent commonly ordered, low-cost, simple, and readily available complete cell count laboratory values and should be used as adjunct tests with reasonable diagnostic accuracy in detecting acute PJIs. Moreover, with its excellent specificity and PPV, MLR could provide valuable insight in diagnosing acute PJI, particularly in male patients. LEVEL OF EVIDENCE: Level III Retrospective Cohort analysis.

A new scoring system for predicting cut-out risk in patients with intertrochanteric femur fractures treated with proximal femoral nail anti-rotation.

OBJECTIVE: The objectives of this study were to: (1) determine all the potential risk factors defined in the literature for cut-out after proximal femoral nail anti-rotation in managing intertrochanteric fractures and (2) make a reliable prediction about the likelihood of cut-out by developing a quantitative scoring system. METHODS: Four hundred eighty patients who were operated on for an intertrochanteric femur fracture were included in the study. The patients were evaluated retrospectively. Radiological parameters known to affect cut-out, including tip apex distance (TAD), calcarreferenced TAD (CalTAD), and reduction quality, were also used to evaluate the patients. Additionally, the classification of the fracture according to the cortical thickness index for osteoporosis, the Charlson comorbidity index for additional comorbidities, and the Arbeitsgemeinschaft Für Osteosynthesefragen classification were evaluated. RESULTS: The cut-out rate among all patients was 7.2%. Cut-out risk could be predicted by gender, TAD, CalTAD, and reduction quality. Female gender, TAD > 29.45, CalTAD > 31.75, and acceptable or poor reduction quality significantly increased the cut-out risk. Based on the chi-square analysis, it was determined that there was a significant relationship between the cut-out risk and the variables of TAD, CalTAD, reduction quality, gender, and fracture type (P=.000, P=.000, P=.000, P=.008, P=.016, respectively). Logistic regression analysis showed a strong correlation between the newly developed scoring system and the risk of cut-out. The risk of cut-out increased 8.1 times in individuals with a score of more than 2 (P < .001). CONCLUSION: Female gender, TAD > 29.45, CalTAD > 31.75, and acceptable or poor reduction quality are the parameters found to be significant in determining the cut-out risk. With the newly developed scoring system, risks can be calculated for all situations that may occur according to the scores obtained by the patients. The cut-out risk increases significantly in patients with a score above 2 points. LEVEL OF EVIDENCE: Level III, Diagnostic Study.

Systematic triage and treatment of earthquake victims: Our experience in a tertiary hospital after the 2023 Kahramanmaras earthquake.

OBJECTIVES: The aim of this study was to evaluate the benefits of our triage system in acceleration of intervention for the musculoskeletal injuries and clinical follow-ups of trauma patients admitted to our center after the Kahramanmaras earthquake. PATIENTS AND METHODS: Between February 6th, 2023 and February 20th, 2023, a total of 439 patients (207 males, 232 females; mean age: 37.1±19.1 years; range, 1 to 94 years) with earthquake-related musculoskeletal injuries after the Kahramanmaras earthquake were retrospectively analyzed. Data including age, sex, referral city information, removal time from the rubbles, physical examination findings, clinical photos, fasciotomy and amputation stumps and levels, and X-ray images and computed tomography images of all patients were shared and archived in the WhatsApp (Meta Platforms, Inc.® ATTN/CA, USA) group called 'Earthquake' created by orthopedic surgeons. To complete the patient interventions as soon as possible and to ensure order, the patients were distributed with the teams in order through this group by the consultant orthopedic surgeon. The treatments were applied and recorded according to the skin and soft tissue conditions, and fractures of the patients. All treatments were carried out with a multi-disciplinary approach. RESULTS: Of the patients, 16.2% were children. Lower limb injuries constituted 59.07% of musculoskeletal injuries. Upper limb, pelvic, and spinal cord injuries were observed in 21.9%, 12.7%, and 6.25%, respectively. Conservative treatment was applied to 183 (41.68%) patients. The most common surgical intervention was debridement (n=136, 53.1%). External fixation was applied in the first stage to 21 (8.2%) patients with open fractures. The mean removal time from the rubbles was 32.1±29.38 h. A total of 118 limb fasciotomy operations were applied to the patients. Fifty limb amputations were performed in 40 patients at the last follow-up due to vascular insufficiency and infection. CONCLUSION: Based on our study results, we believe that a triage system using a good communication and organization strategy is beneficial to prevent treatment delay and possible adverse events in future disasters.

Hyperbaric oxygen therapy does not change the amputation level in patients with fasciotomy after an earthquake: Our single-center experience after 2023 Kahramanmaras earthquake.

OBJECTIVES: This study aims to evaluate the effect of hyperbaric oxygen therapy (HBOT) on the amputation level in patients undergoing fasciotomy with a Mangled Extremity Severity Score (MESS) score of ≥7 after 2023 Kahramanmaras earthquake. PATIENTS AND METHODS: Between February 6th, 2023 and March 10th, 2023, a total of 23 patients (14 males, 9 females; mean age: 36.8±13.2 years; range, 17 to 64 years) who needed amputation with a MESS score of ≥7 and refused amputation were included in the study. All fasciotomies were performed in an external center, and five of them was incomplete. First, incomplete fasciotomies were completed with debridement due to deep muscle necrosis. Daily two HBOT sessions were performed for the first three days. In the following days, daily one HBOT session was performed. The HBOT was terminated for the patients who were decided by the council that they did not benefit from HBOT treatment. RESULTS: Six (26.08%) of the patients had a bone fracture (n=2 forearm, n=1 femur, n=2 tibia, and n=1 ankle fracture). The mean number of HBOT session was 13.24±5.4 (range, 7 to 30) and the mean duration of HBOT was 26.5±10.8 (range, 14 to 60) h. The mean MESS score was 9.96±1.36 (range, 7 to 12). All of the patients were trapped under the rubble with a mean time of 12.3±5.4 (range, 6 to 23) h. All fasciotomies were performed within the first 30 h. Twenty-two of the patients were amputated at the level previously determined by the experienced trauma surgeons. The amputation level changed in only one patient. After 38 h of HBOT, transradial amputation was performed to the patient in whom transhumeral amputation level was determined previously. None of the patients had any adverse event related to HBOT. CONCLUSION: Our study results suggest that the MESS is a useful scoring system for amputation decision after a high-energy trauma, such as an earthquake, with a high accuracy rate. The outcomes of HBOT are not satisfactory for high-energy traumas, such as earthquakes, in those requiring fasciotomy having more muscle necrosis and a MESS score of ≥7.

Preventing extremity amputations after earthquakes: a quantitative analysis of fasciotomy and extrication time.

PURPOSE: The purpose of this study is to evaluate the impact of prolonged extrication time and the time to fasciotomy applications on amputation requirement by giving quantitative and cutoff values. METHODS: In this single-center study, the clinical records of patients with musculoskeletal injuries due to the 6 February Kahramanmaras earthquake in Turkey were retrospectively reviewed. All patients who underwent fasciotomy or amputation regardless of age and gender were included in the study. 163 extremities of 140 patients who met the inclusion criteria were evaluated. Demographic data of the patients, such as age and gender, were recorded in this study. The primary outcome of this study was the correlation of the time between injury and fasciotomy applications with the amputation requirement. At the same time, the effect of prolonged extrication time of earthquake victims on amputation requirement. RESULTS: The mean age was 29.01 ± 15.55 of earthquake victims included in the current study and the gender distribution of the patients is almost equal. 87 amputations of 65 patients were performed and transtibial amputation was the most common type (41.3%). The mean fasciotomy time was 38.78 ± 23.64 h. Delayed fasciotomies performed after 45.5 h increase 28.48 times the amputation requirement. The mean extrication time in the current study was 36.49 h. The patients with extrication time longer than 23 h was associated with an 8.8 times higher risk of amputation. CONCLUSIONS: Authors believe that knowledge of the relationship between earthquake survivors' prognosis and time of extrication, as well as the impact of fasciotomy timing on extremity loss, is essential for a more successful treatment management in future disasters.

Impact of Posterior Malleolus Fixation on Clinical and Functional Results.

BACKGROUND: Clinical studies have shown that posterior malleolar fractures treated with a posterior buttress plate have improved outcomes compared to anterior-to-posterior screw fixation. The aim of this study was to evaluate the impact of posterior malleolus fixation on clinical and functional results. METHODS: The patients with posterior malleolar fractures who were treated between January of 2014 and April of 2018 at our hospital were investigated retrospectively. Fifty-five patients included in the study were divided into three groups according to the fixation preferences of fractures (group I, posterior buttress plate; group II, anterior-to-posterior screw; and group III, nonfixated). The groups consisted of 20, nine, and 26 patients, respectively. These patients were analyzed according to demographic data, fixation preferences of fractures, mechanism of injury, hospitalization length of stay, surgical time, syndesmosis screw use, follow-up time, complications, Haraguchi fracture classification, van Dijk classification, American Orthopaedic Foot and Ankle Society score, and plantar pressure analysis. RESULTS: There were no statistically significant differences between the groups in terms of gender, operation side, injury mechanism, length of stay, anesthesia types, and syndesmotic screw usage. However, when the age, follow-up time, operation time, complications, Haraguchi classification, van Dijk classification, and American Orthopaedic Foot and Ankle Society scores were evaluated, statistically significant differences were observed between the groups. Plantar pressure analysis data showed that group I yielded balanced pressure distribution between both feet compared to the other study groups. CONCLUSIONS: The posterior buttress plating of posterior malleolar fractures yielded better clinical and functional outcomes compared to the anterior-to-posterior screw fixation and nonfixated groups.