Modified and alternative bone cements can improve the induced membrane: Critical size bone defect model in rat femur.

BACKGROUND: As a two-stage surgical procedure, Masquelet's technique has been used to care for critical-size bone defects (CSD). We aimed to determine the effects of modified and altered bone cement with biological or chemical enriching agents on the progression of Masquelet's induced membrane (IM) applied to a rat femur CSD model, and to compare the histopathological, biochemical, and immunohistochemical findings of these cements to enhance IM capacity. METHODS: Thirty-five male rats were included in five groups: plain polymethyl methacrylate (PMMA), estrogen-impregnated PMMA (E+PMMA), bone chip added PMMA (BC+PMMA), hydroxyapatite-coated PMMA (HA) and calcium phosphate cement (CPC). The levels of bone alkaline phosphatase (BALP), osteocalcin (OC), and tumor necrosis factor-alpha (TNF-α) were analyzed in intracardiac blood samples collected at the end of 4 weeks of the right femur CSD intervention. All IMs collected were fixed and prepared for histopathological scoring. The tissue levels of rat-specific Transforming Growth Factor-Beta (TGF-ß), Runt-related Transcription Factor 2 (Runx2), and Vascular Endothelial Growth Factor (VEGF) were analyzed immunohistochemically. RESULTS: Serum levels of BALP and OC were significantly higher in E+PMMA and BC+PMMA groups than those of other groups (P = 0.0061 and 0.0019, respectively). In contrast, TNF-α levels of all groups with alternative bone cement significantly decreased compared to bare PMMA (P = 0.0116). Histopathological scores of E+PMMA, BC+PMMA, and CPC groups were 6.86 ± 1.57, 4.71 ± 0.76, and 6.57 ± 1.51, respectively, which were considerably higher than those of PMMA and HA groups (3.14 ± 0.70 and 1.86 ± 0.69, respectively) (P < 0.0001). Significant increases in TGF-ß and VEGF expressions were observed in E+PMMA and CPC groups (P = 0.0001 and <0.0001, respectively) whereas Runx2 expression significantly increased only in the HA group compared to other groups (P < 0.0001). CONCLUSIONS: The modified PMMA with E and BC, and CPC as an alternative spacer resulted in a well-differentiated IM and increased IM progression by elevating BALP and OC levels in serum and by mediating expressions of TGF-ß and VEGF at the tissue level. Estrogen-supplemented cement spacer has yielded promising findings between modified and alternative bone cement.

Fluroscopy-assisted transiliac antegrade lag screw placement technique in both columns of acetabulum: A novel procedure.

The use of pelvic osseous fixation corridors and lag screw fixation in acetabular and pelvic surgery has gained popularity, especially with the recent development of intraoperative imaging and navigation techniques. However, advanced intraoperative imaging and navigation techniques require technical equipment and are costly. Therefore, traditional fluoroscopic techniques still maintain their importance. In this article, we describe a novel pelvic osseous fixation corridor that traverses both columns of the acetabulum, along with the detailed methodology of its fluoroscopic imaging and the techniques for fluoroscopy-assisted screw placement. The technique of placing screws in this current fixation corridor is only under fluoroscopy assistance, without using any specially produced guide or navigation device. LEVEL OF PROOF: IV.

The antibiotics supplemented bone cement improved the masquelet's induced membrane in a rat femur critical size defect model.

BACKGROUND: Masquelet technique is a two-stage surgical procedure used in the treatment of critical-size bone defects (CSD). Adding antibiotics to polymethylmethacrylate (PMMA) is still questionable to create higher quality induced membrane (IM). The aim of the study was to evaluate the effects of three antibiotic-supplemented cement, fusidic acid, teicoplanin, and gentamicin, on osteogenesis and IM progression applied to rat femur CSD model by comparing histopathological, biochemical, and immunohistochemical findings. METHODS: Twenty-eight male rats were divided into four groups control, gentamicin (G), teicoplanin (T), and fusidic acid (FA). A 10 mm CSD was created in rat femurs. In the postoperative 4th week, intracardiac blood samples were collected for biochemical analysis of bone alkaline phosphatase (BALP), osteocalcin (OC), and tumor necrosis factor-alpha (TNF-α) levels. IMs obtained in secondary operation were fixed and prepared for histopathological scoring of membrane progression and immunohistochemical evaluation of rat-specific Transforming Growth Factor-Beta (TGF-ß), Runt-related Transcription Factor 2 (Runx2), and Vascular Endothelial Growth Factor (VEGF) expressions. RESULTS: Levels of BALP and OC in serum didn't change among groups significantly while serum TNF-α levels significantly decreased in all antibiotic groups compared to the control group (P = 0.017). Histological scores of groups FA and T were significantly higher than those of groups Control and G (P = 0.0007). IMs of groups T and FA showed good progression while those of groups Control and G were also moderately progressed. A significant increase in TGF-ß expression was observed in group G and FA (P = 0.001) while a significant increase in the expression of VEGF was observed in groups G and T compared to the control group (P = 0.036). CONCLUSIONS: The bone cement impregnated with thermostable and safe antibiotics, gentamicin, fusidic acid, and teicoplanin can increase osteogenesis and support IM progression by increasing the expressions of TGF-ß and VEGF. Anabolic effects of induced membranes used in the treatment of critical-size bone defects can be enhanced by antibiotic-supplemented PMMAs applied by altering the original technique.

Fibular fixation improves ankle functional outcomes and alignment in the intramedullary nailing of distal third tibiofibular diaphyseal fractures.

PURPOSE: The study aims to determine the effect of fibular fixation on alignment and fracture healing of tibia, and ankle functional outcomes in the treatment of distal third tibiofibular diaphyseal fractures. METHODS: Consecutive 111 patients (33 females and 78 males) with distal third tibiofibular diaphyseal fracture who met the inclusion criteria were included in the study. Patients were divided into two groups as those who underwent fibular fixation with tibia intramedullary nailing (study group) and those who did not (control group). Groups were compared in terms of demographic features, trauma and fracture characteristics, functional and radiological outcomes. RESULTS: No significant difference was observed between the groups in terms of demographic features, trauma characteristics, complications, and follow-up time (p > 0.05). Surgery time was significantly lower in the control group (p = 0.001). Ankle joint range of motion, AOFAS score, OMAS score, and full weight-bearing time were significantly better in the fibular fixation group (p = 0.023, p = 0.001, p = 0.001 and p = 0.039, respectively). Significantly better coronal alignment and sagittal alignment were found in the fibular fixation group (p = 0.001 and p = 0.001, respectively). Patients who underwent fibular fixation had significantly better radiological outcomes in terms of fibular rotation angle and ankle arthrosis (p = 0.000 and p = 0.022, respectively). CONCLUSION: Fibular fixation not only contributes to fracture union, early full weight-bearing, and alignment but also improves ankle functional outcomes in the distal third tibiofibular fractures treated with intramedullary nailing for tibia. LEVEL OF EVIDENCE: Level III, retrospective study.

The common comorbidities leading to poor clinical outcomes after the surgical treatment of ankle fracture-dislocations.

BACKGROUND: The ankle fracture-dislocations are a significant traumatic incident for the bone and the soft tissue surrounding the ankle. Bone stabilization, joint immobilization, anatomic reduction and intervention for soft tissue protection should be performed as early as possible. The present study aims to determine the frequency of major comorbidities that can be seen after surgery in patients with ankle fracture-dislocations and the relationship between the trauma mechanism and clinical status with these comorbidities. METHODS: Thirty-eight patients (25 males, 13 females) who underwent surgery with ankle fracture-dislocations between May 2014 and February 2017 were evaluated retrospectively in this study. All patients were evaluated clinically and radiologically at least 24 months postoperatively. Arthrosis, synostosis, presence of the chondral lesion and AOFAS scores were detected for all patients. RESULTS: Mean AOFAS score was lower in open ankle fracture-dislocations than in closed dislocations (p=0.044). An accompanying osteochondral lesion (OCL) and increased patient age were found to be strongly associated with the development of arthrosis (p=0.005 and p=0.017; respectively). Four of 29 patients who received primer definitive surgery and four of nine patients who received step-by-step surgery had poorly calculated AOFAS scores (p=0.071). There was no significant relationship between dislocation direction and AOFAS scores (p=0.087). CONCLUSION: Clinical and functional results were found to be worse in patients with open ankle fractures, the rate of arthrosis increased with age, and the use of syndesmosis screw had a positive but not a statistically significant effect on clinical and functional outcomes.

Acute correction and intramedullary nailing of aseptic oligotrophic and atrophic tibial nonunions with deformity.

OBJECTIVES: This study aims to describe the important points for treatment of aseptic tibial oligotrophic and atrophic nonunions by intramedullary nailing (IMN). PATIENTS AND METHODS: The retrospective study included 17 biologically nonactive nonunion patients (12 males, 5 females; mean age 36.4 years; range, 19 to 49 years) operated between February 2010 and November 2017 by deformity correction, static IMN and autografting. The mean follow-up time was 4.2 (range, 3 to 7) years. The initial fracture management was external fixator for all patients. Fourteen patients had open fractures initially. Six patients had valgus, four patients had varus, three patients had oblique plane, and four patients had external rotational deformity. Nonunion diagnosis was established on the basis of the patient history and physical examination based on plain radiographs, computed tomography or both. All patients were evaluated by the same protocol to exclude any infection. RESULTS: The median time from injury to nailing was mean 10.3 (range, 6.1 to 36.5) months. Radiologic and clinical union was achieved in all patients. The mean union time was 3.64 (range, 3 to 6) months. Three patients had positive intraoperative bacteriological culture. In four patients, dynamization was necessary for consolidation. Late deep infection developed in three patients after union, and all infected cases were operated by implant removal, debridement, and appropriate antibiotics. CONCLUSION: Intramedullary nailing and autografting after external fixator provide good results for the treatment of aseptic biologically nonactive nonunions with deformity. Reamed IMN ensures sufficient deformity correction, biological environment, and mechanical stability. The infection risk should always be kept in mind and patients should be followed-up closely to prevent complications.

Multidisciplinary approach in the treatment of osteoid osteoma with radiofrequency ablation.

OBJECTIVES: This study aims to present the importance of a multidisciplinary approach to radiofrequency ablation (RFA) treatment in osteoid osteoma (OO) patients by a team of experts in their field in preventing recurrence and complications. PATIENTS AND METHODS: For this retrospective study, a team of two orthopedists, two interventional radiologists, and one anesthesiologist was established in January 2013 to manage the diagnosis, follow-up, and treatment process of patients with OO at Bakirköy Dr. Sadi Konuk Training and Research Hospital. A total of 27 patients (15 males, 12 females; mean age 22.9 years; range, 9 to 54 years) were treated by this team between February 2013 and September 2016. The anatomic localization included iliac crest in four patients, the femur in 12 patients, fibula in two patients, humerus in three patients, radius in one patient, tibia in three patients, talus in one patient, and metacarpal in one patient. The procedures were carried out by the same interventional radiologists, same orthopedic surgeons, and same anesthesiologist in the computed tomography (CT) unit under aseptic conditions. After appropriate anesthesia for the localization of OO, the patient was positioned on the CT bed and the localization of the lesion was confirmed with a CT scan mapping. Then, a bone penetration cannula was advanced and bone cortex was penetrated with a charged motor and Kirschner (K)-wire. When the cannula reached the nidus, it was replaced with RFA probe. Ablation of the nidus was performed for five minutes at 90°C. RESULTS: The mean follow-up period was 46 months (range, 25 to 66 months). Patients were evaluated with visual analog scale (VAS) scores preoperatively and at postoperative 15th day, sixth month, and first year. In the last evaluation of the study data, the patients were called by telephone and questioned whether there were any changes in their final status. The mean preoperative VAS score was 7.2. The mean postoperative VAS scores of the 15th day, sixth month, and first year were 1.3, 0.6, and 0, respectively. In the last follow-up, the OO-related pain completely disappeared and none of the patients had any recurrence. There was a significant difference between preoperative and postoperative 15th day and sixth month VAS score measurements. CONCLUSION: Radiofrequency ablation treatment of OOs is a minimally invasive, safe, low-cost, and efficient method. We believe that with experienced teams and appropriate planning, RFA will take part in practice as the standard treatment of OO.

The role of trauma mechanism, fracture pattern and fixation technique on clinical outcomes and epiphyseal growth arrest in the surgical treatment of distal tibial epiphysiolysis.

BACKGROUND: Distal tibial epiphyseal fractures damage to epiphyseal growth plate. Epiphyseal growth arrest (EGA), reflex sympathetic dystrophy and ankle joint stiffness may also occur after distal tibial epiphyseal injury. This study aims to evaluate the role of trauma mechanism, fracture pattern and fixation technique on clinical outcomes and EGA in the surgically treated distal tibial epiphyseal fractures. METHODS: Twenty seven patients who underwent surgery for distal tibial epiphyseal fracture between the 2011 and 2017 were evaluated retrospectively. The effects of trauma mechanism, fixation technique, preoperative duration, fracture patterns on the clinical results and EGA were examined. AOFAS (The American Orthopedic Foot and Ankle Score) and MOXFQ (The Manchester-Oxford Foot Questionaire) were used for clinical evaluation. RESULTS: Twenty seven patients (17 male and 10 female) were included in this study. The most important complication of epiphyseal injury was the growth pause in eight patients. No statistically significant difference was observed concerning clinical scores and complications according to trauma mechanism, fixation techniques and fracture patterns (p>0.05). CONCLUSION: Regardless of the trauma mechanism, fracture pattern and the fixation material, an anatomical reduction should be obtained in distal tibial epiphyseal fractures to reduce complications and prevent the EGA.

The relationship between injury mechanism and sexual dysfunction in surgically treated pelvic fractures.

PURPOSE: The aim of the study was to identify the incidence of new sexual dysfunction reported by the patient in surgical treatment of pelvic ring injuries, and to describe the relationship between new sexual dysfunction and type of fracture. METHODS: Ninety-five patients who were operated for pelvic fracture were included in the study. Patients were evaluated according to age, gender, marital status, body mass index, trauma mechanism, fracture classification, genitourinary injury, accompanying injury, injury severity score, surgical technique, fixation material, duration of operation, functional outcomes, blood loss, complications, and sexual dysfunction. Functional outcomes were assessed with Female Sexual Functioning Index (FSFI), International Index of Erectile Function-5 (IIEF5), Arizona Sexual Experience Scale (ASEX), and Modified Majeed's pelvic outcomes grading scale (MPS). RESULTS: Genitourinary symptoms were erectile dysfunction (ED) in 13 men, ejaculatory dysfunction in 9 men, and dyspareunia in 23 women. Urethral stricture developed in 4 males and 1 female with the urethral injury. FSFI score, ASEX score, and MPS score showed the statistically significant difference between the fracture types (p = 0.021, p = 0.032 and p = 0.020, respectively). There were no significant difference between fracture types in terms of the IIEF5 score, and no significant relationship between fracture type and ED development (p = 0.141). CONCLUSION: Anteroposterior compression (APC) is the most common cause of sexual dysfunction in both sexes, independent of surgery. In addition, the most common cause of ED in men is vertical shear (VS). Especially patients with APC and VS injuries should be multidisciplinary evaluated with gynecology, urology, and psychiatry departments.

Comparison of the functional results of radial head resection and prosthesis for irreparable mason type-III fracture.

BACKGROUND: The radial head is essential for the rotational stability of the forearm and resistance to valgus stress. Radial head fractures are the most common elbow fracture in adults. Various treatment options are available, depending on the fracture severity. However, the treatment of Type-III fractures is controversial. The aim of this study was to evaluate functional results in patients with irreparable Mason Type-III radial head fractures treated with radial head resection or prosthesis. METHODS: Fourteen irreparable Mason Type-III radial head fracture patients treated with radial head resection (n=7) or radial head prosthesis (n=7) were evaluated in this multicenter, retrospective study. Disabilities of the Arm, Shoulder and Hand (DASH) and Mayo Elbow and Wrist scores were used to determine clinical outcomes. A hydraulic hand dynamometer was used to measure grip strength on the operated and unoperated sides to avoid potential bias. Measurements were made three times for each extremity, and the mean value was recorded. Grip strength was calculated as a percentage of the strength of the unoperated side. RESULTS: Functional outcomes for resection and prosthesis patients were the following: mean DASH scores, 25.8 and 17.2; mean Mayo Elbow scores, 74 and 84.1; mean Mayo Wrist scores, 84 and 92.5; and maximum grip strengths, 48.8% and 77.8%, respectively. The range of motion of the respective resection and prosthesis groups were as follows: flexion, 112.14° and 104.29°; extension, -10.00° and -25.00°; pronation, 70.00° and 47.86°; and supination, 70.00° and 52.14°. CONCLUSION: Although range of motion was restricted in the radial head resection group, functional results and grip strength were superior in patients treated with a radial head prosthesis. These results support the radial head prosthesis as a superior treatment modality for patients with irreparable Mason Type-III radial head fractures with respect to patient satisfaction and functional outcomes.

Volar locking plate versus K-wire-supported external fixation in the treatment of AO/ASIF type C distal radius fractures: A comparison of functional and radiological outcomes.

BACKGROUND: The aim of this study was to compare the functional and radiological outcomes of K-wire-supported bridging external fixation (KW-EF) and volar locking plate (VLP) in the treatment of comminuted intra-articular distal radius fractures. METHODS: Patients treated for complex intra-articular distal radius fractures between February 2010 and April 2013 were retrospectively investigated. A total of 114 patients (42 females and 72 males) with a mean age of 44.9±15.4 (range: 18-86) years were evaluated. Wrist ranges of motion were measured using a universal goniometer, and hand grip strength was determined using hand dynamometers. The results were evaluated with Gartland-Werley score. QuickDASH questionnaire was administered in subjective functional assessment. Radiological evaluations were performed, with wrist radiographs obtained on the 3rd month and 2nd year. RESULTS: Wrist flexion, extension, pronation, and supination were all significantly better in the VLP group than in the KW-EF group at last control (p=0.001). Gartland-Werley, QuickDASH, and Visual Analog Scale were significantly better in the VLP than group than in the KW-EF group (p=0.003, p=0.003, and p=0.001, respectively). At the last follow-up, loss of grip strength compared with that on the uninjured side was 4% in the VLP group and 7% in the KW-EF group. CONCLUSION: VLP is a safe method with low complication rates. It is superior to KW-EF as it facilitates early return to daily activities and shows better functional and radiological outcomes in the 2nd year of treatment.

Platelet-rich plasma versus exchange intramedullary nailing in treatment of long bone oligotrophic nonunions.

INTRODUCTION: The aim of the study was to evaluate the effects of platelet-rich plasma on healing rates and healing time in the treatment of long bone nonunions treated by an intramedullary nail previously. MATERIALS AND METHODS: Between August 2008 and January 2012, 14 consecutive patients who were treated for long bone nonunions with percutaneous platelet-rich plasma application (PRP) were included in the study. The control group included 15 consecutive patients who were treated with exchange intramedullary nailing (EIN). In the postoperative period, all patients were controlled in every 2 weeks clinically and in every 4 weeks radiologically. Patients were evaluated with visual analog scale (VAS) in preoperative and postoperative periods. RESULTS: The mean healing time was shorter in PRP group as 16.71 ± 2.4 weeks compared with that of 19.07 ± 3.67 weeks in EIN group (p = 0.053). At the end of the follow-up, the union is achieved in 92.8% of the cases in PRP group. This ratio was 80% in control group. The mean VAS values in preoperative and postoperative periods were not statistically significant in both groups (p > 0.05). When PRP and control groups were evaluated individually, the postoperative VAS was lower than that of preoperative VAS in both groups (p = 0.0001 and p = 0.0001, respectively). CONCLUSION: Percutaneous PRP application significantly affected union rate, but no significant difference found when compared to EIN in the treatment of oligotrophic nonunions after intramedullary nailing of long bone fractures. PRP can be applied as a minimally invasive and safe method of saving resources in medical care instead of EIN.

The role of intraoperative cell salvage system on blood management in major orthopedic surgeries: a cost-benefit analysis.

INTRODUCTION: The aim of this study was to compare the efficiency and cost of cell salvage systems with allogeneic blood transfusions in patients who had major elective orthopedic surgeries. MATERIALS AND METHODS: Consecutive 108 patients who had intraoperative cell saver (CS) performed routinely constitute the study group. In control group, consecutive 112 patients who were operated without intraoperative CS were investigated. Hemoglobin (Hb) level less than 8 mg/dL was regarded as the absolute transfusion indication. The patients were evaluated for age, gender, body mass index, operation period, mean intraoperative estimated blood loss (EBL), postoperative hemovac drainage volume; preoperative, postoperative first day and discharge Hb levels, allogeneic blood transfusion (ABT) volume, hospitalization and cost parameters. RESULTS: The mean intraoperative EBL was 507 mL in the study group and 576 mL in control group. The mean ABT was 300 mL in the study group and 715 mL in control group. In the study group, intraoperative EBL, ABT usage and hospitalization period were significantly lower compared with the control group (p = 0.009, p = 0.000 and p = 0.000; p < 0.05, respectively). The mean cost was 771 Turkish liras (TL) in the study group and 224 TL in control group. In the study group, the cost was significantly higher than the control group (p = 0.000). The postoperative first day Hb level was significantly higher in the study group (p = 0.010). CONCLUSION: Although CS usage was determined to increase the costs in this study, it significantly decreases intraoperative and postoperative ABT requirements. We believe that the increase in cost may be neglected when the complications and prolonged hospitalization due to ABT usage were regarded.

Intraobserver and interobserver reliability assessment of tibial plateau fracture classification systems.

OBJECTIVES: This study aims to assess the intra- and interobserver reliability of commonly used tibial plateau fracture classification systems. PATIENTS AND METHODS: This retrospective cohort study included computed tomography (CT) and plain radiographic images (lateral and anteroposterior X-rays) of 60 patients (40 males, 20 females; mean age 45.9 years; range 18 to 80 years) who presented to two orthopaedic clinics between January 2011 and January 2015 with unilateral tibial plateau fractures. All plain X-rays (XR) and CT images were evaluated by four observers on two separate occasions, 1.5 months apart. All fractures were classified according to the Arbeitsgemeinschaft für Osteosynthesefragen-Orthopaedic Trauma Association (AO-OTA), Schatzker, Hohl and Moore, Luo and revised Duparc systems. Intraobserver reliability was measured with Cohen's kappa (κ) coefficient and interobserver reliability with Fleiss' kappa coefficient. RESULTS: When Schatzker classification was performed, interobserver reliability was in moderate level for (κ=0.51) for XR and in substantial level for CT (κ=0.61). When AO/OTA classification was used, interobserver reliability was in moderate level for both methods of diagnosis (κXR=0.43 and κCT=0.54, respectively). In the Hohl and Moore classification, the interobserver reliability was also moderate for both methods of diagnosis (κXR=0.45 and κCT=0.51, respectively). Revised Duparc classification showed the lowest interobserver reliability ranging from fair to moderate level (κXR=0.27-0.55 and κCT=0.44-0.61). Interobserver reliability for Luo classification was κCT=0.47. Intraobserver reliability for CT in Luo classification was in substantial level for observers 1, 2 and 3 (κCT=0.67-0.71) and in perfect level for observer 4 (κCT=0.84). Intraobserver reliability was in substantial level in Schatzker classification and in moderate level at the other classifications. CONCLUSION: Among the classification systems compared in this study, Schatzker was the most reliable particularly when CT was used. On the other hand, revised Duparc classification presented the worse reliability results due to its complexity and different morphological subtypes.

Bicolumnar 90-90 plating of AO 13C type fractures.

OBJECTIVE: The aim of this study was to evaluate functional results and complication rate of patients who underwent medial-dorsolateral plating for intra-articular distal humeral fracture (Müller AO type 13C). METHODS: Twenty-four patients (14 men, 10 women; mean age: 47 years) with AO type 13C distal humerus fracture were included in the study. Mean follow-up time was 28 months. Nine patients were in 13C1 subgroup, according to AO classification system, 11 patients were categorized as 13C2, and 4 patients were 13C3. Final follow-up assessment of outcomes included Broberg and Morrey radiological criteria; Mayo Elbow Performance Score, disabilities of the Arm, Shoulder and Hand (DASH) Outcome Measure, score based on Jupiter criteria; and range of motion (ROM) values. RESULTS: The mean carrying angle of operated elbows was 11.37° (range: 0-20°). According to Broberg and Morrey radiological criteria, 14 patients, had radiologically normal elbow, 4 patients had mild change, 3 patients had moderate change, and 3 patients had severe radiological change. Mean DASH score was 21.91 (range: 0-50), and mean Mayo rating was 83.37 (range: 55-100). Jupiter criteria evaluation revealed excellent results in 10 cases, good in 12, and fair results in 2. One patient with fair result had open fracture, and the other had previous hemiparesis in the same extremity. There was no instance of nonunion observed at follow-up. CONCLUSION: Osteosynthesis with medial-dorsolateral plating is a safe and effective method for the treatment of intra-articular fractures of distal humerus. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Orthopedic trauma surgery and hospital cost analysis in refugees; the effect of the Syrian civil War.

PURPOSE: The aim of this study was to evaluate the musculoskeletal injury types, injury mechanisms, surgical techniques and treatment costs of Syrian refugees. METHODS: Totally 158 patients (67 female, 91 male) treated in our clinic in 34 months period between January 2012 and October 2014 were included in the study. The mean age of the patients was 39.3 years (range: 18-82 years). The patients were evaluated for age, gender, mechanism of injury, location and type of fracture, presence of accompanying injuries, injury severity score, surgical technique, complications, mortality/morbidity and treatment cost. RESULTS: The injuries were more frequently reported in lower extremities, upper extremities and axial skeleton, respectively. Blunt trauma was significantly higher in upper extremity injuries compared with the other types of injuries (p = 0.001). Fractures were most commonly reported in foot/ankle region and in males, hand/wrist fractures were significantly higher than that of the females. Plate fixation of upper extremity fractures and intramedullary nailing in lower extremity fractures were the most commonly preferred treatment modalities. The mean hospitalization period of patients was 5.6 days and the mean treatment cost was 3844 Turkish Liras (TL). CONCLUSIONS: In this study, it was shown that there was a statistically significant increase in the cost of health expenses in patients with fall from heights or gunshot wound, with fractures in axial skeleton or with the ISS score between 16 and 66. The cost rise was associated with worse prognosis, complications, intensive care treatments and prolonged hospitalization periods.

Medial mini-open versus percutaneous pin fixation for type III supracondylar fractures in children.

BACKGROUND: The present objective was to compare medial mini-open and percutaneous treatment of pediatric supracondylar fractures according to fluoroscopy time, duration of surgery, and iatrogenic ulnar nerve injury. METHODS: A total of 104 Gartland type III supracondylar humerus fractures were prospectively evaluated between 2011 and 2013. Patients were divided into 2 groups according to type of fixation. In Group A (41 patients), medial pin was inserted with mini-open incision with 2 lateral pins inserted percutaneously. In Group B (63 patients), all pins were inserted percutaneously. Mean follow-up time was 14.1±1.2 months in Group A, and 14.6±2.1 months in Group B. All patients were postoperatively evaluated for nerve injury with both motor and sensory function assessment. Length of surgery, total fluoroscopy time, fluoroscopy time for medial pin insertion, Baumann's angle, humeral capitellum angle, final carrying angle, and range of motion were recorded. RESULTS: Sensorial evaluation showed that Group A had 3 poor, and 1 fair results, and Group B had 2 poor, and 1 fair results. No statistically significant differences were observed, including no differences in either surgery or total fluoroscopy times between groups. However, fluoroscopy time during medial pin placement was significantly lower in the mini-open group. CONCLUSION: In conclusion, similar results of both techniques were observed, and both carry risk of iatrogenic ulnar nerve injury. Medial pin placement is easier and less demanding when used with mini-open technique.

Talar Osteochondroma Fracture Presenting as Posterior Ankle Impingement.

Osteochondromas are the most common benign bone tumors. They are usually asymptomatic and found incidentally. When symptomatic, the symptoms are usually due to its location and size. Fracture of an osteochondroma presenting as posterior ankle impingement is a rare condition. We describe a 22-year-old man with solitary exostosis who presented with a posterior ankle mass and posterior ankle impingement with 2 years of follow-up. Surgical intervention was the treatment of choice in this patient, and histologic examination revealed a benign osteochondroma. Osteochondromas found in the posterior aspect of the talus can be complicated by fracture due to persistent motion of the ankle. Talar osteochondroma should be included in the differential diagnosis of posterior ankle impingement causes. Posterior talar osteochondromas, especially when a stalk is present, should be treated surgically before it is more complicated by a fracture and posterior ankle impingement.

The outcome and parents-based cosmetic satisfaction following fixation of paediatric supracondylar humerus fractures treated by closed method with or without small medial incision.

Supracondylar humerus fractures are common in children. Displaced fractures are usually treated with closed reduction and cross pin fixation. But, medial pinning may cause the ulnar nerve injury. The aim of this study was to compare the parents-based cosmetic satisfaction of the incision scars in children with displaced supracondylar humerus fractures treated by closed reduction and cross pin fixation with or without small medial incision. We retrospectively reviewed the medical records of 72 children with displaced supracondylar humerus fractures treated two different closed reduction and percutaneous pinning methods at our institution from January 2010 through December 2013. A group has 36 patients treated with small medial incision and crossed K-wires fixation after closed reduction. The other group has 36 patients treated with closed reduction and K-wires fixation. At the final follow-up, the patients were evaluated radiologically and clinically with Flynn's criteria. Furthermore, a visual analogue scale was used to determine of the parents-based cosmetic satisfaction score. All fractures healed without major complications at the final clinical and radiological assessment. Although, between the two groups did not differ in terms of Flynn cosmetic and functional outcomes, there were statistically significant differences between both groups according to the parents-based cosmetic satisfaction scores. The closed reduction and crossed pin fixation without small medial incision should be preferred first because of better the parents-based cosmetic satisfaction.

Computed tomography evaluation of the iliac crest apophysis: age estimation in living individuals.

Determination of the ossification properties of the iliac apophysis is important not only in the clinical evaluation of patients undergoing orthopedic surgery but also in age estimation studies for forensic purposes. The literature includes both anthropological and radiological (conventional radiography, ultrasonography, and magnetic resonance imaging modalities) investigations of the different staging systems used for these purposes. In this study, we assessed the utility of computed tomography (CT) of the iliac crest apophysis in estimating forensic age. CT scans of the iliac crest apophysis of 380 patients (187 females, 193 males, and 10-29 years of age) were evaluated according to the four-stage system. Further subclassification did not give data properly due to the reference length measurement of the iliac wing with CT. Thus, in our series, stage 2 was first seen in 12 years of age and stage 3 in those 14 years of age in both sexes and on both sides of the pelvis. Stage 4 was first seen in 17 years of both sexes but only on the right side; on the left side, it appeared in females 18 years of age and in males 17 years of age. Present data was found consistent with previous pelvic radiographic findings. First seen ages for stage 2 and 3 are 12 and 14 years respectively which presented valuable information for legally important age thresholds. However, disadvantages of CT, including high-dose radiation exposure to gonads, the difficulty of evaluating the iliac crest, and the age boundary of 17 years, could make this method infeasible, as compared with hand wrist and pelvic radiographic methods. CT of the iliac crest has probably a greater utility where preexisting CT scans of the pelvic region are available, and it may be considered as a supportive method for age-estimation purposes.