Does sagittal alignment of the femoral component have an impact on radiological loosening and functional results in revision knee arthroplasty?

OBJECTIVES: In this study, we aimed to investigate the effect of sagittal alignment of the femoral component on both radiological loosening and functional results in revision total knee arthroplasty (rTKA), as well as the anterior condylar offset (ACO) and posterior condylar offset (PCO). PATIENTS AND METHODS: Between December 2005 and November 2020, a total of 47 patients (12 males, 35 females; mean age: of 67.1±8.4 years; range, 52 to 90 years) who underwent rTKA due to aseptic prosthesis failure were retrospectively analyzed. Demographic data including age, sex, body mass index (BMI), and clinical outcomes of the patients were recorded. Early postoperative sagittal alignment of the femoral component, ACO, and PCO were measured. Radiological loosening of patients was evaluated using the modified Knee Society Score, while the functional outcomes were assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS). RESULTS: The mean follow-up was 55.4±28.0 (range, 24 to 142) months. While there was a moderate and inverse correlation between the sagittal alignment of the femoral component and ACO (p=0.002), there was no significant correlation between the sagittal alignment of the femoral component and PCO (p=0.980). There was a weak and inverse correlation between BMI and KOOS (p=0.024). There was no significant relationship between the sagittal alignment of the femoral component, ACO, PCO, age, and sex with radiological loosening (p=0.241) or KOOS (p=0.894). CONCLUSION: In rTKA, sagittal alignment of the femoral component does not affect radiological loosening and functional results. The sagittal alignment of the femoral component exhibits a moderate and inverse correlation with ACO, while it has no significant correlation with PCO.

Late-Diagnosed Dislocation of the Proximal Interphalangeal Joint of the Fifth Toe in a 7-Year-Old Boy: A Case Report.

Dislocation of the proximal interphalangeal joint of the fifth toe is an uncommon injury. When it is diagnosed in the acute phase, closed reduction is commonly an adequate treatment option. We describe a rare case of a 7-year-old patient who presented with late-diagnosed isolated dislocation of the proximal interphalangeal joint of the fifth toe. Although there are a few reported cases of late-diagnosis combined fracture-dislocation of the toes in both adult and pediatric age groups in the literature, belatedly diagnosed dislocation of the fifth toe without accompanying fracture in the pediatric population, to our knowledge, has not yet been reported. This patient achieved good clinical outcomes after treatment via open reduction and internal fixation.

A comparison of exchange nailing and plate augmentation over a retained intramedullary nail in aseptic oligotrophic and atrophic femoral shaft pseudoarthrosis.

OBJECTIVES: This study aims to evaluate the success of plate augmentation over a retained intramedullary nail (IMN) against exchange nailing performed with autologous bone grafting in oligotrophic and atrophic pseudoarthrosis of the femoral shaft. PATIENTS AND METHODS: Between May 2005 and October 2020, a total of 42 of 56 patients (28 males, 14 females; mean age: 47.3±17.2 years; range, 19 to 84 years) with aseptic atrophic or oligotrophic femoral nonunion were retrospectively analyzed. The patients, 20 were operated with plate over a retained IMN, and the rest (n=22) by exchange nailing. Data including demographic and clinical characteristics of the patients, treatment success, duration of surgery, blood loss during surgery, infection rates, length of hospital stay, time to bridging of the nonunion site, and time to obliteration of the fracture line (solid union) were recorded. RESULTS: The mean follow-up was 23.8±20.4 (range, 12 to 96) months in the plate over an IMN group and 34.7±27.4 (range, 12 to 90) months in the exchange nailing group. At the final follow-up, solid union occurred in all of the patients in the plate augmentation over a retained IMN group, and 21 of 22 (95.45%) patients in the exchange nailing group. Blood loss during surgery was significantly less in the plate augmentation over IMN group (p=0.027). There was no statistically significant difference in the other variables between the two groups (p>0.05). CONCLUSION: Our study results demonstrate that plate over a retained IMN is effective as exchange nailing in the surgical treatment of oligotrophic and atrophic pseudoarthrosis of the femoral shaft. However, it can be speculated that plate application over IMN is more advantageous in terms of blood loss during surgery.

Pediatric infrafossal fracture of the humerus: A case series.

OBJECTIVES: In this case series, we aimed to evaluate the clinical and radiographic outcomes of the patients with infrafossal fracture of the humerus and to evaluate the upper extremity and elbow function with the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. PATIENTS AND METHODS: Between January 2005 and July 2020, the clinical data and radiographs of 2,443 children who were treated due to distal humerus fracture were retrospectively analyzed. A total of six patients (5 males, 1 female; mean age: 6.7±2.6 years, range, 3 to 11 years) treated due to an infrafossal fracture of the humerus were included. Radiographic measurements, such as Baumann's angle, lateral capitellohumeral angle, and carrying angle of the elbow, were performed. At the final follow-up, elbow joint range of motion (ROM) was measured, functional scores of the elbow and upper extremity were assessed. Complications were also recorded. RESULTS: The mean follow-up was 62.8±47.4 (range, 20 to 140) months. Two patients underwent open and three underwent closed reduction and internal fixation by different surgeons. One of the patients was treated with a long-arm cast. There was no major elbow ROM limitation. There was no significant deterioration in the lateral capitellohumeral and elbow carrying angles of the patients. Baumann's angle was normal for all the patients; however, it could not be measured in two patients, as their epiphyses were closed. Four patients had an excellent MEPS and two patients a good MEPS. The QuickDASH scores were low in all patients. There were two patients with cubitus varus who were treated surgically using lateral closing-wedge corrective osteotomy. CONCLUSION: Infrafossal fracture of the humerus is a fracture type which is different from supracondylar and transcondylar fractures and has not been previously reported in the literature. Despite the cubitus varus developed in two of our patients, functionally satisfactory results were achieved in all patients at the end of the treatment. Due to the risk of developing cubitus varus, patients with infrafossal fracture of the humerus should be followed closely until the end of adolescence. Although the current study is very limited in terms of being a guide for the treatment, it may contribute to the literature in terms of defining a new fracture subtype.

Comparison of radiographic vs. computed tomography canal filling ratio measurement of stems in revision knee prostheses.

Background: Lack of consensus on which measurement method gives the most accurate results for medullary canal filling ratio (CFR) of stems used in revision knee prostheses causes confusion when interpreting scientific studies. Therefore, the present study aims to find the most accurate measurement method of CFR on direct radiographs. Methods: Twenty-eight femoral and 27 tibial components of 29 patients with a mean age of 72.86 ± 6.32 years were included in the study. Two different methods were used for computerized tomography CFR measurement. These methods and five different radiographic measurement methods used for CFR were compared statistically. Results: There was no statistically significant difference between the real tomographic CFR of the femoral stem and the CFR calculation made by using ellipse area (p > 0.05). There was also no statistically significant difference between the tomographic CFR measurement calculated according to the largest stem size that can be implanted, and the method that accepted the smallest value as CFR after the measurement made according to Parsley's method on AP and lateral radiographs (p > 0.05). The results obtained by using all other tests were statistically different from each other. Conclusion: CFR calculation made by using ellipse area, is the most accurate method for femoral stem CFR. The method that accepted the smallest value as CFR after the measurement made according to Parsley's method on AP and lateral radiographs is the most accurate method for tibial stem CFR.

An evaluation of intra and inter observer reliability of the five used classification systems of tibial plateau fractures.

We aimed to evaluate the intraobserver and inter- observer variations of the five primary classification systems for assessing tibial plateau fractures via standard X-Ray, biplanar and reconstructed 3D CT images. Using anteroposterior (AP) - lateral X-Ray, and CT images, one hundred tibial plateau fractures were evaluated and classified by four surgeons according to the AO, Moore, Schatzker, modified Duparc, and 3-column classification systems. Each observer evaluated the radiographs and CT images separately - listed each time randomly - on a total of 3 occasions: with an initial evaluation, and then subsequently in weeks 4 and 8. Intra- and interobserver variabilities were assessed using the Kappa statistics. Intra- and interobserver variabilities were 0.55 ± 0.03 and 0.50 ± 0.05 for AO, 0.58 ± 0.08 and 0.56 ± 0.02 for Schatzker, 0.52 ± 0.06 and 0.49 ± 0.04 for Moore, 0.58 ± 0.06 and 0.51± 0.06 for the modified Duparc, and 0.66 ± 0.03 and 0.68 ± 0.02 for the 3-column classification. Evaluation of tibial plateau fractures using 3-column classification in conjunction with radiographic classifications has higher levels of consistency compared to radiographic classifications alone.

Adolescent tibial tubercle fractures in the time of the COVID 19: A single orthopedic trauma center experience.

BACKGROUND: The purpose of this study is to assess the incidence and clinical characteristics of adolescent tibial tubercle fractures (TTFs) during the COVID-19 pandemic by sharing our experiences. METHODS: Pediatric patients aged between 0 and 18 years old with confirmed diagnosis of TTFs who were treated at our center between April 2020 and May 2020 were included in the study. In addition to demographics, mechanism injury, treatment modalities, complications were also noted. RESULTS: Sixteen patients were included in the study. The mean age was 14.8 ± 0.9 years (range: 13-16 years). The mean BMI of patients was 26.3 ± 2.3 kg/m2 (range: 23.2-30.4 kg/m2). According to the BMI-for-age percentiles growth chart, eight patients (50%) were overweight, and eight patients (50%) were at a risk of being categorized as overweight. The most common cause for the injury was jumping due to basketball (50%). Twelve of 16 patients were treated operatively by open reduction and internal fixation. The remaining 4 patients were treated non-operatively with long leg cast. CONCLUSION: The incidence of TTFs was 16 cases over about two months during the pandemic isolation period. Our results demonstrated that all adolescent TTFs occurred during periods when outdoor activities were permitted. This finding may be explained by sudden athletic activity after prolonged immobilization. We observed that all of our patients were male and either overweight or at risk of being overweight.

Evaluation of the Parameters Affecting Respiratory Functions at Adolescent Idiopathic Scoliosis Patients.

STUDY DESIGN: This was a retrospective observational study. OBJECTIVE: The objective of the study was to evaluate the spinal and extraspinal factors responsible for pulmonary dysfunction in adolescent idiopathic scoliosis patients. SUMMARY OF BACKGROUND DATA: Development of thoracic deformity due to scoliosis results with the restrictive ventilatory pattern and the reduced pulmonary function. To prevent pulmonary function deterioration, it is imperative to understand which factors are causing the restrictive lung disease in adolescent idiopathic scoliosis patients. MATERIALS AND METHODS: An online database search was conducted in a hospital computerized archive between 2008 and 2018 years. Cobb angle of >30 degrees, Lenke type 1 and 2 patients treated in a single spine unit were included. Coronal and sagittal Cobb angle, bending correction rate for evaluation of flexibility, Risser score, apical vertebra rotation (AVR), and pulmonary function test of patients were obtained. RESULTS: There was a moderate negative correlation between forced expiratory volume in the first second, forced vital capacity, and AVR. There was no correlation between forced expiratory volume in the first second and forced vital capacity with age, sex, Cobb angle, Risser score, kyphosis, and bending correction rate. CONCLUSIONS: When considering the results of the current study and the other studies in the literature there is not any strong correlation between the features of scoliotic curvature and respiratory functions. In the current study, 52 (72.22%) of 72 patients with moderate to severe scoliosis had mild to severe respiratory dysfunction. Considering the age-related physiological respiratory loss, to evaluate the necessity of surgical treatment in patients with moderate and severe scoliosis, especially in patients with high AVR, the respiratory functions of the patient should also be evaluated. LEVEL OF EVIDENCE: Level III.

Intramedullary nailing versus minimally invasive plating in the treatment of distal tibial extra-articular fractures: Comparison of cost analysis in Turkey.

BACKGROUND: Minimally invasive percutaneous plate osteosynthesis (MIPO) and intramedullary nailing (IMN) are the two most commonly used methods for distal tibial extra-articular fractures; however, the ideal treatment is still on debate. The aim of this study was to compare MIPO and IMN in the treatment of distal tibial extra-articular fractures in terms of cost analysis according to health insurance records in Turkey. METHODS: The data of patients who underwent either MIPO or IMN for the treatment of distal tibial extra-articular fractures between 2013 and 2018 were analyzed in this retrospective study. Patients' clinical data, as well as the overall expenses from the first admission until return to work including hospitalization, and all outpatient controls had been reviewed from the hospital's billing department. The total amount of money paid per month by Turkish National Social Security Institution to the patient until the patient's returns to work were also recorded. RESULTS: 118 consecutive patients (35 female-83 male) with the mean age of 37.2±13.4 were participated to the study. IMN group consisted of 57 patients with a mean age of 36.7±12.8 years, and MIPO group consisted of 61 patients with a mean age of 37.8±13.6 years. No significant differences were observed between study groups in terms patients' age, gender, fracture classification (AO/OTA: Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association), soft-tissue injury (Tscherne classification), presence of type 1 open fracture, and presence of accompanying fibula fracture. There was no statistical difference between two groups in terms of pre-operative hospital stay (p=0.713). However, the mean length of hospital stay was significantly higher in the MIPO group (p=<0.001). The means of number of total outpatient controls, time to union, and return to work were also significantly higher in the MIPO group (p=0.005, p<0.001 and p<0.001, respectively). The mean hospital cost until discharge and the mean total cost until return to work were significantly higher in the MIPO group (p=0.001 and 0.001, respectively). The mean total costs of hospital stay and outpatient controls were also significantly higher in the MIPO group (p=0.001 and 0.004, respectively). The mean implant costs did not significantly differ between groups (p=0.179). CONCLUSION: According to the results acquired from the present study, IMN is a better option compared to MIPO for the treatment of extra-articular distal tibial fractures in terms of costs paid by the national health insurance in Turkey.

Femoral stem fractures after primary and revision hip replacements: A single-center experience.

OBJECTIVES: This study aims to present our experience in the management of fractured femoral stems after primary and revision hip replacements by evaluating the clinical and radiographic characteristics and determining the effectiveness of the extraction methods. PATIENTS AND METHODS: A total of 15 patients (5 males, 10 females; mean age 65.9 years; range, 49 to 87 years) who underwent revision hip replacement due to a fractured femoral stem between January 2005 and December 2019 were included in this retrospective study. The mechanisms and risk factors for failure as well as methods applied to extract fractured stem were analyzed through clinical and radiographic data. RESULTS: Nine patients had fractured cemented femoral stems, while six patients had fractured fully porous coated cementless revision stems. Lack of proximal buttress in distally fixed femoral stems was detected in 11 patients and identified as the predominant mechanism resulting in fracture. The proximal extraction method with conventional revision instrumentation, the cortical window technique, and extended trochanteric osteotomy (ETO) were used in three, seven, and five cases, respectively. CONCLUSION: Our results demonstrated that the lack of proximal buttress is the most common reason for femoral stem fracture. Moreover, the proximal extraction method was mostly ineffective in fully porous femoral stems. A step-by-step approach should be considered for the extraction of a broken stem. The cortical window method can be considered as the second step if proximal extraction methods fail, and ETO should be considered at the last step if all techniques fail.

Modified Woodward Technique for Sprengel Deformity and a Modification of the Cavendish Classification.

INTRODUCTION: Sprengel deformity (SD) is the most common congenital anomaly of the shoulder. Surgery is required for moderate and severe forms. The modified Woodward procedure is the most widely used procedure for the surgical treatment. METHODS: SD patients who applied to our institution between 2005 and 2018 were retrospectively reviewed. A modification of the Cavendish classification was used for preoperative and postoperative evaluations. RESULTS: Eighteen shoulders of 17 (mean age: 8.5 y, range: 2 to 18 y, 5 males and 12 females) patients were included. The right, left, and bilateral shoulders were affected in 9, 7, and 1 cases, respectively. The mean follow-up time was 62.9 months (12 to 161 mo). Preoperatively, 3 shoulders were type 2, 12 shoulders were type 3, and 3 shoulders were type 4 according to the Cavendish classification and 2 shoulders were type 0, 6 shoulders were type 1, and 10 shoulders were type 2 postoperatively. CONCLUSIONS: Periscapular congenital malformations play a significant role in range of motion limitation. The modified Woodward procedure is a viable alternative in the surgical treatment of SD and the proposed modification of Cavendish classification (grade 0) is functional.