Elastic Stable Intramedullary Nailing in Length Stable Versus Unstable Pediatric Femoral Shaft Fractures: A Comparison of Clinical, Radiographic, and Pedobarographic Outcomes.

BACKGROUND: Pediatric diaphyseal femoral fracture (PDFF) is one of the most common injuries requiring hospitalization. Elastic stable intramedullary nailing (ESIN) is commonly used for PDFFs in ages 5 to 11. The optimal treatment method for length unstable PDFF is a subject of ongoing debate. This study aimed to compare clinical, radiographic, and pedobarographic outcomes of ESIN between length stable and unstable PDFF. METHODS: We retrospectively reviewed patients undergoing ESIN treatment for isolated PDFF between 2016 and 2021. Exclusion criteria were (1) history of ipsilateral or contralateral lower extremity fractures, (2) highly comminuted or segmental fractures, (3) body weight >50 kg, and (4) comorbidities affecting bone quality, range of motion, or neurologic status. The patients were divided into 2 groups according to length stability. Clinical, radiographic, and pedobarographic data were then assessed to compare groups. RESULTS: Twenty-five patients were included (17 length stable and 8 length unstable PDFF) with a mean age of 73.6±17.8 months. There was no significant difference between groups in age, side of injury, body weight, follow-up duration, and nail-canal diameter ratio. Mean deformity in the fracture site in the early postoperative x-rays was not significantly different between groups (P=0.661). After a mean follow-up of 27.8±14.2 months (range, 12-67), there was no significant difference in mechanical axis deviation, distal femur joint orientation angle, or limb-length discrepancy in both groups. The pedobarographic assessment revealed that the length unstable group had a significantly higher external foot progression angle in the injured extremity (9.8°±6.9° vs. 1.3°±5.6°, P=0.031). However, the length stable group had no significant difference in the foot progression angle (4.9°±5° vs. 3°±4.3°, P=0.326). There was no significant difference in either group for other pedobarographic parameters. CONCLUSION: ESIN is a safe and effective option for length-unstable PDFF, yet attention should be paid to the rotational alignment. Although significant external rotation deformity occurs in length-unstable PDFF, it has no implications for the other pedobarographic parameters. LEVEL OF EVIDENCE: Level IV.

Extended Interportal Capsulotomy for Hip Arthroscopy, a Single-Center Clinical Experience.

Background and Objectives: The number of hip arthroscopy procedures is on the rise worldwide, and awareness regarding proper management of the hip capsule has increased. No capsulotomy shape is agreed upon as a standard approach, with literature supporting both isolated interportal and T-shaped capsulotomies. The aim of this retrospective cohort study is to report the clinical results of a standardized extended interportal capsulotomy (EIPC) during hip arthroscopy. Materials and Methods: Patients operated on between 2017 and 2020 with a hip arthroscopy were eligible. The inclusion criteria were ages 18-60 years, failed non-operative treatment, and at least a 2-year follow-up. Exclusion criteria were bilateral femoroacetabular impingement syndrome (FAS) cases or labral lesions, ipsilateral knee injury, history of ipsilateral hip surgery, and significant spine lesions. Data regarding demographic characteristics such as age, gender, operation date, BMI, but also Beighton score, presence of postoperative pudendal nerve damage, and revision for any reason were gathered from patients' records. All patients were evaluated preoperatively with a visual analog scale (VAS), the Hip Disability and Osteoarthritis Outcome Score (HOOS), and the modified Harris Hip Score (mHHS). Results: Of the 97 patients operated on with a hip arthroscopy between the defined dates, only 90 patients were included. The mean age was 37.9 ± 9.8, and 58.9% of patients were male. The most frequent surgical indication was an isolated FAS lesion (73.3%), followed by FAS associated with a labral tear (12.2%), an isolated labrum tear (10.0%), synovitis (3.3%), and a loose body (1.1%). The mean follow-up for the study cohort was 39.3 months. The majority of the patients had uneventful surgeries (76.7%), while there were three cases of sciatic nerve neuropraxia and 12 cases of pudendal nerve neuropraxia. Two patients underwent revision surgery during the study period. Comparison between preoperative and postoperative clinical scores showed a significant improvement with a final mHHS mean value of 67.7 ± 18.2, an HOOS value of 74.1 ± 13.2, and a low VAS score of 1.3 ± 1.2. Conclusions: A hip arthroscopy procedure with a standardized and unrepaired, extended interportal capsulotomy is a safe procedure with satisfactory mid-term results and high overall patient satisfaction. At a minimum of 2 years and a mean of 39.2 months, patients showed improved clinical scores and a low revision rate.

Laterally Protruded Cephalomedullary Nail Lag Screws are a Source of Consistent Thigh Pain After Pertrochanteric Fracture.

OBJECTIVES: To assess the correlation between the amount of proximal screw lateralization and clinical symptoms in patients treated with a cephalomedullary nail (CMN) after a pertrochanteric fracture. DESIGN: Retrospective study. SETTING: Level 1 trauma center. PATIENT SELECTION CRITERIA: Patients operated for a pertrochanteric fracture (OTA/AO A1, A2, A3) between 2019 and 2022 and treated with a CMN were included. OUTCOME MEASURES AND COMPARISONS: Three measurements were evaluated: D1 distance between the most laterally prominent point of the lag screw and the line tangent to the greater trochanter, D2 distance between the lateral femoral cortex and the most laterally prominent point of the lag screw, and D3 distance between the point where the lag screw emerges at the lateral edge of the femur shaft and the skin's surface. Clinical scores and information regarding lateral thigh pain were obtained, and a correlation analysis was performed. RESULTS: Mean age of the study cohort (n = 134) was 77.9 ± 12.3 years. Patients with categorical protrusion (considered present in cases where the distance between the lateral tip of the lag screw and the lateral border of the greater trochanter was ≥0.2 mm) had significantly higher rates of lateral thigh pain ( P = 0.007) and discomfort while lying on the side ( P = 0.032) compared with those without protrusion. Correlation analyses showed a positive correlation between measurements D1 and D2 and lateral thigh pain (r = 0.324 and r = 0.334, respectively, P < 0.001) and a negative correlation between D3 and lateral thigh pain (r = -0.286, P = 0.001). Regression analysis showed that higher D1 and D2 distances and shorter D3 distances are risk factors for lateral thigh pain ( P = 0.001, 0.001, and 0.002, respectively). CONCLUSIONS: Increasing lateral protrusion of the lag screw leads to significantly greater clinical complaints and lateral hip pain in patients treated with a CMN. Patients with lower distance between the lateral femoral wall and the skin are at higher risk of lateral pain. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Dual activity of Minnelide chemosensitize basal/triple negative breast cancer stem cells and reprograms immunosuppressive tumor microenvironment.

Triple negative breast cancer (TNBC) subtype is characterized with higher EMT/stemness properties and immune suppressive tumor microenvironment (TME). Women with advanced TNBC exhibit aggressive disease and have limited treatment options. Although immune suppressive TME is implicated in driving aggressive properties of basal/TNBC subtype and therapy resistance, effectively targeting it remains a challenge. Minnelide, a prodrug of triptolide currently being tested in clinical trials, has shown anti-tumorigenic activity in multiple malignancies via targeting super enhancers, Myc and anti-apoptotic pathways such as HSP70. Distinct super-enhancer landscape drives cancer stem cells (CSC) in TNBC subtype while inducing immune suppressive TME. We show that Minnelide selectively targets CSCs in human and murine TNBC cell lines compared to cell lines of luminal subtype by targeting Myc and HSP70. Minnelide in combination with cyclophosphamide significantly reduces the tumor growth and eliminates metastasis by reprogramming the tumor microenvironment and enhancing cytotoxic T cell infiltration in 4T1 tumor-bearing mice. Resection of residual tumors following the combination treatment leads to complete eradication of disseminated tumor cells as all mice are free of local and distant recurrences. All control mice showed recurrences within 3 weeks of post-resection while single Minnelide treatment delayed recurrence and one mouse was free of tumor. We provide evidence that Minnelide targets tumor intrinsic pathways and reprograms the immune suppressive microenvironment. Our studies also suggest that Minnelide in combination with cyclophosphamide may lead to durable responses in patients with basal/TNBC subtype warranting its clinical investigation.

Unrepaired Trochanteric Bursae as a Risk Factor for Deep Gluteal Syndrome After Total Hip Arthroplasty: A Prospective Randomized Controlled Trial.

BACKGROUND: The trochanteric bursae are often left unrepaired after total hip arthroplasty (THA) and they retract posteriorly over the muscle belly of the piriformis. Deep gluteal syndrome (DGS) is a multifactorial condition presenting as buttock pain and is attributed to nondiscogenic sciatic nerve irritation or impingement causes. The purpose of this study was to investigate the relationship between bursal repair and incidence of DGS in patients undergoing THA. METHODS: This prospective randomized trial included patients treated with a THA between January and December 2022 for a diagnosis of primary osteoarthritis. Patients were randomized into 2 groups: group 1 underwent a routine bursal repair, while group 2 did not, leaving the bursae unrepaired. Follow-up was performed on the 15th, 30th, and 90th day postoperatively with clinical scores, physical examinations, and laboratory tests. In this cohort of 104 patients, mean age was 55 years (range, 26 to 88). Demographic variables as well as range of motion and overall clinical results showed no significant difference between the groups. RESULTS: DGS rates were significantly more common in the patients who had an unrepaired bursa (group 2) both on the 30th and 90th postoperative days, while comparison of lateral trochanteric pain on palpation showed similar results between the groups. CONCLUSIONS: DGS is common in individuals who have unrepaired trochanteric bursal tissue following a THA. Despite its higher frequency, these symptoms did not have a substantial impact on the overall clinical scores, which remained consistent across the study groups.

Are There Any Significant Risk Factors Associated with Lateral Trochanteric Pain in Patients Who Have Undergone Primary Hip Replacement?

Introduction Lateral pain around the greater trochanter (LTP) is a common complication after total hip arthroplasty (THA) that can significantly reduce quality of life. The aim of this study was to analyze the relationship between lateral trochanteric bursa repair, subcutaneous fat thickness, and trochanteric pain during the THA procedure. Materials and methods A total of 98 patients who underwent THA for hip arthrosis between 2021 and 2022 were evaluated retrospectively. For all evaluated patients, subcutaneous thickness was measured between the fascia and the skin at the incision site. Bursa repair was performed in 47 patients, while bursa excision was done in 51 patients. The data obtained included demographic information, functional scores, comorbidities, bursa repair and skin thickness values, radiographic evaluations, and other specific markers. These were compared between patients diagnosed with LTP following THA and the controls. Results No difference was observed between the study groups in terms of subcutaneous fat thickness, bursa repair, and other demographic or radiographic evaluations. As expected, there were statistically significant differences between the groups in terms of the visual analog scale (VAS) score (p=0.030) and the Harris hip score (HHS) (p=0.045). When comparing the groups with and without LTP, the VAS score was higher in the group with LTP, while the HHS was found to be lower. Conclusion Trochanteric pain is not associated with bursa repair or subcutaneous thickness. LTP cannot be predicted based on comorbidities such as smoking, BMI, or radiographic measurements.

Better sex after hip arthroscopy; Sexual dysfunction in patients with femoro-acetabular impingement syndrome.

BACKGROUND: Femoro-acetabular impingement syndrome (FAIS) is a common cause of hip pain and functional decline. The quality of life of affected patients has been shown to be significantly diminished, with potential alterations in the ability to perform activities of daily living and recreation, including sexual function. Hip arthroscopy is the surgical technique recognized as the gold standard in FAIS. The aim of this study was to research the relationship between hip arthroscopy due to FAIS and pre- and postoperative sexual function. HYPOTHESIS: The hypothesis of the study was that sexual dysfunction would be common during the preoperative period but would significantly improve after surgery. MATERIALS AND METHODS: This retrospective study included 96 patients aged 18 to 55 years, who underwent hip arthroscopy for a FAIS diagnosis between 2015 and 2021, with a minimum follow-up of one year. Exclusion criteria were a bilateral symptomatic hip condition, history of ipsilateral hip or knee surgery, history of urological or gynecological conditions, sexual dysfunction, or a history of hip osteonecrosis or osteoarthritis. The Female Sexual Function Scale (FSFI) was used to evaluate sexual dysfunction in females and the International Erectile Function Index (IIEF-5) for males. RESULTS: The patients comprised 56.3% males and 43.82% females with a mean age of 35.3±8.3 years. Sexual dysfunction was determined preoperatively in 85.2% of the males and in 57.1% of the females. Overall improvement after surgery was statistically significant. Signs of pudendal nerve damage were seen during the postoperative period in 29 (30.2%) patients. The change in total sexual scores was significantly correlated with nerve symptoms and regression analysis showed that traction time was a significant risk factor for pudendal nerve symptoms. DISCUSSION: Sexual dysfunction is a common trait of patients suffering from FAIS and the majority of patients significantly benefit from the procedure. Sexual dysfunction persists in a category of patients during the postoperative period, regardless of the type of lesion, and this phenomenon is associated with transient pudendal nerve symptoms, which are more likely to occur with longer traction times and thus represent a clear risk factor. LEVEL OF EVIDENCE: IV.

A clinical comparison of two different surgical techniques in the treatment of acute Achilles tendon ruptures: Limited-open approach vs. percutaneous approach.

BACKGROUND: Surgical treatment is the commonly preferred method for treating acute Achilles tendon ruptures (AATRs) due to advantages such as less re-rupture rates, better functional results, and an early return to physical activities. The main aim of our study is to compare two common minimally invasive surgical methods, the limited open and the percutaneous approaches, regarding clinical outcomes. METHODS: A total of 53 patients (19 females and 34 males) who were treated with limited open (Group 1: 30 patients) and percutaneous (Group 2: 23 patients) approaches for AATRs were retrospectively evaluated between March 2019 and May 2020 in a level 1 trauma center. The evaluation included complications (soft tissue and skin problems, re-rupture, and sural nerve injury rates), the operation time, the duration of return to daily activities, The Achilles Tendon Total Rupture Score (ATRS), and the American Ortho-pedic Foot and Ankle Society (AOFAS) scores of the patients at the first and 6th months of follow-up. Patients' activity levels were compared with the Tegner Activity Scale (TAS). RESULTS: The mean age of all patients in this cohort was 45.1±14.1. The mean postoperative follow-up period for group 1 was 36.9±8.81 weeks, whereas, for group 2, it was 35.4±8.73 weeks (P=0.24). The mean age (P=0.47), gender distribution (P=0.41), and body mass index (P=0.29) were similar for both groups. The mean operation time (group 1: 47.1±5.4 vs. group 2: 44.4±6.1, P=0.06) and the duration of return to daily activities (group 1: 49.2±7.4 vs. group 2: 48.5±9.7, P=0.38) were also similar. There was no statistical difference between groups regarding functional results at first (ATRS: group 1: 79.9±3.2 vs. group 2: 79.5±3.9, [P=0.35], and AOFAS: group 1: 80.9±3.1 vs. group 2: 82.1±3.2, [P=0.10]) and 6th months (ATRS: group 1: 85.0±3.8 vs. group 2: 83.7±4.4, [P=0.13], and AO-FAS: group 1: 86.6±3.6 vs. group 2: 86.7±4.2, [P=0.46]). There were no statistically significant differences between groups regarding preoperative and last follow-up TAS scores (P= 0.94 and P=0.46, respectively). We observed no postoperative complications in group 1. There were three complications (13.1%) in group 2. One patient (4.4%) had a re-rupture, and two patients (8.7%) had sural nerve injuries. CONCLUSION: Although both groups had similar functional results, the limited open approach yielded better clinical outcomes according to the complication results than the percutaneous approach.

Comparison of dermatotraction and negative pressure wound therapy for closure of cruris fasciotomy after 2023 Kahramanmaras earthquake.

OBJECTIVES: This study aims to evaluate the results of patients who underwent cruris fasciotomy for acute compartment syndrome (ACS) after the 2023 Kahramanmaras earthquake and used subcuticular polydioxanone (PDS) method or negative pressure wound therapy (NPWT) with vacuum-assisted closure (VAC) for fasciotomy follow-up and closure of the defect. PATIENTS AND METHODS: Between March 2023 and April 2023, a total of 52 patients (31 males, 21 females; mean age: 29±14.8 years; range, 5 to 74 years) were retrospectively analyzed. The patients were divided into two groups as the dermatotraction (PDS) group (Group 1, n=30), and the VAC group (Group 2, n=22). Data including demographic, clinical, and operative data such as fasciotomy closure time, graft need, and infection rate were recorded. RESULTS: More grafts were needed to close the fasciotomy in patients followed with VAC. The mean closure time of the fasciotomy was 25.9±3.8 days in the PDS group and 27.3±3.5 days in the VAC group, indicating no significant difference between the groups (p=0.738). There was no significant difference in the rate of wound infection between the two groups (p=0.482). CONCLUSION: Our study results suggest that more grafts are needed to close the fasciotomy in patients followed with VAC; however, it seems to increase the cost of the treatment.

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.

Clinical Examination Findings Can Accurately Diagnose Developmental Dysplasia of The Hip-A Large, Single-Center Cohort.

BACKGROUND: Physical examination findings such as limited hip abduction (LHA), asymmetric skin creases (ASC), and a popping sensation in the hip facilitate the diagnosis of developmental dysplasia of the hip (DDH). Screening with a simple physical examination during the first weeks of infancy is important for early detection of the condition, and a wide range of medical professionals, including general practitioners, obstetricians, pediatricians, and orthopedic surgeons etc. are involved in this process. The aim of this study was to determine the correlation between easily recognizable physical examination findings such as LHA, thigh/groin ACSs, and Ortolani and Barlow tests with ultrasound findings for the diagnosis of DDH. METHODS: This study included 968 patients undergoing routine hip ultrasonography between December 2012 and January 2015. All patients were examined by an experienced orthopedic surgeon who was not the physician who performed the ultrasound examination to exclude bias between physical examination findings and ultrasound findings. Asymmetric skin folds (thigh and groin), limited abduction, Barlow and Ortolani tests were recorded. The relationship between the physical examination findings, ultrasound findings, and developmental dysplasia was investigated. RESULTS: Of the 968 patients, 523 were female (54%) and 445 were male. On ultrasonography examination, 117 patients were found to have DDH. The sensitivity, specificity and negative predictive values of patients who were found to have both LHA and thigh/groin ASCs in all three physical examinations were high (83.8%, 70.2%, and 96.9%, respectively) while positive predictive values were found to be low (27.8%). CONCLUSION: Asymmetric skin creases on the thigh and groin and limited hip abduction, when evaluated together, have high sensitivity and specificity with additional high negative predictive values and could help during the initial screening process of DDH.

Clinical and radiological comparison of bioactive glass and poly-L-lactic acid/hydroxyapatite bioabsorbable interference screws for tibial graft fixation in anterior cruciate ligament reconstruction.

BACKGROUND: Ligament reconstruction is still the main treatment modality for patients with a complete ligament rupture. The semitendinosus tendon, alone quadrupled or double folded and combined with the gracilis tendon, is still the most frequently used autologous graft for a reconstructive procedure. Absorbable interference screw usage has gained popularity in the past decade because they create less artifacts during MR imaging and tend to osteointegrate over the years, arguably leading to a more anatomic fixation. The purpose of this study was to compare the 5-year radiological and clinical results of two different tibial graft fixation screws. HYPOTHESIS: We hypothesized that bioabsorbable interference screws made of bioactive glass would lead to higher rates of osteointegration, better overall clinical results, less foreign body reaction rates and less tibial tunnel widening when compared to the poly-L-lactic acid/hydroxyapatite (PLLA-HA) screws. PATIENTS AND METHODS: Fifty-one patients treated with an anatomic single bundle ACL reconstruction between June 2015 and July 2016 at our institution were included in the study. The tibial graft was fixed with a bioactive glass screw in 24, and with a PLLA-HA in 27 patients. Tibial tunnel widening, foreign body reaction, osteointegration and resorption rates were evaluated and compared on a magnetic resonance scan at a minimum of 5 year postoperatively. Overall clinical results and side-to-side difference on KT-1000 were also analyzed in-between groups. RESULTS: Tibial tunnel widening was similar for both groups. Foreign body reaction, while not statistically significant, was less aggressive when bioactive glass screws were used. Osteointegration and resorption rates of the bioactive glass screws were significantly higher than the PLLA-HA group (p=0.000). While all patients showed an overall improvement on postoperative scores (p=0.000), patients with a bioactive glass interference screw had statistically higher translational stability with KT-1000, compared to the poly-L-lactic acid/hydroxyapatite group (p=0.001). DISCUSSION: At a minimum of 5 years, compared to conventional PLLA-HA interference screws, 45S5 bioactive glass screw provide higher resorption rates, are more highly biodegradable and provide overall good clinical results. LEVEL OF EVIDENCE: III.