Novel radiographic hip fat thickness ratio correlates with early re-operation following total hip arthroplasty.

INTRODUCTION: Obesity is thought to lead to increased failure rates following total hip arthroplasty (THA). Site-specific fat distribution has been suggested to be a better indicator of risk, compared to body mass index. Fat thickness measurement methods were developed for total knee arthroplasty, however, there is limited data on the methods for THA. The aim of this study was to assess the interobserver and intraobserver reliability of a newly defined radiographic subcutaneous fat thickness ratio and investigate the correlation of this ratio with early failure following THA. METHODS: 321 patients who underwent primary THA at a single institution between 2014 and 2017, with at least 1-year of follow-up and a preoperative pelvis anteroposterior x-ray radiograph were included in this study. A high hip fat thickness ratio (HFTR) was arbitrarily defined as ⩾2. Early failure was defined as revision or re-operation for any reason and death related to operation first year following THA. RESULTS: The HFTR was shown to have excellent intraobserver and interobserver reliability. High HFTR was associated with higher risk of early failure following THA (odds ratio 3.8, [95% confidence interval, 1.2-12.1], p < 0.05). The same association persisted when HFTR was analysed as a continuous variable (p < 0.01) and in multivariate analysis (p < 0.05). CONCLUSIONS: HFTR can be used to assess periarticular soft tissue distribution and may be regarded as a useful and reproducible tool for assessing risk of early failure following THA.

Could superior capsule findings be used as a predictor for partial bursal-sided rotator cuff tears?

PURPOSE: The purpose of this study was to investigate the relationship between the superior capsule tear patterns and synovitis with subacromial pathologies, such as bursal-sided rotator cuff tear and subacromial impingement syndrome. METHODS: Fifty patients who underwent arthroscopic treatment for isolated bursal-sided tear were included in the study. Fifty more patients who underwent arthroscopic treatment for isolated Superior Labrum Anterior Posterior (SLAP) 2 lesion without pathology in the rotator cuff were included in the control group. Firstly, superior capsule tear and common synovitis on the rotator cable were assessed during glenohumeral joint examination. Coracoacromial Ligament (CAL) degeneration grading was performed according to the Royal Berkshire Hospital classification. Bursal-sided partial tear grading was done using Ellman classification. Whether or not there was a relationship between synovitis, classic capsule tear, plus reverse flap capsule tear, and partial bursal-sided tear existence. RESULTS: There were 21 patients with reverse flap capsule tear in the study group and 3 patients in the control group. In addition, there were 13 patients with synovitis in the study group and 4 in the control group. Compared to the control group, there was also a significant positive correlation in the presence of both synovitis and reverse flap capsule tear with the presence of bursal-sided tear in the study group (p = 0.000). There was, however, no significant difference between the presence of classical capsule tear and the presence of bursal-sided tear (p = 0.485). CONCLUSION: This study shows that the presence of reverse flap capsule tear and synovitis was associated with partial bursal-sided tears. Therefore, if the reverse flap capsule tear or synovitis is detected in the superior capsule, the rotator cuff should be evaluated in more detail during subacromial bursoscopy in order not to miss a bursal-sided partial cuff tear.

Can a Hip Diagnosed as Graf Type 1According to Graf Checklist Deteriorate Over Time? A Case Series and Evaluation of the Graf Method.

INTRODUCTION: According to the Graf method, mature Type 1 hips will not worsen overtime. However, some cases have been reported in literature of hips which were initially Graf Type 1 hips and then worsened later. Our aim is to show the mistakes of the hip sonograms, which had been diagnosed as a mature Graf Type 1 hips. CASE REPORT: A review of literature revealed four studies initially diagnosed as Graf Type 1 hips and which then worsened overtime. Professor Graf has previously stated that measurements from inappropriate sonograms may result in an incorrect diagnosis. In this paper, the four aforementioned studies and their sonograms reported in literature were evaluated according to the Graf technique. In the light of the findings, it was discussed whether a mature hip could worsen overtime. In the reported cases, some of the deficiencies according to the Graf checklist were determined. CONCLUSION: From this examination, it can be concluded that Type 1 mature hips which worsened overtime, except for special circumstances as previously mentioned by Professor Graf, are related to an initial wrong diagnosis. As a result, if a Graf Type 1 hip was determined appropriately according to Graf checklist, it will never worsen later in normal circumstances.

The role of ADAMTS genes in the end stage of hip osteoarthritis.

PURPOSE: The aim of this study is to investigate which ADAMTS genes play a major role in the development of primary hip osteoarthritis, by comparing the tissue and blood samples in patients with hip osteoarthritis and a control group. MATERIAL AND METHODS: Human articular cartilage was obtained from femoral heads of 15 patients with end stage osteoarthritis undergoing total hip replacement. As the control group, the cartilages was obtained from femoral heads of 15 patients, who did not have osteoarthritis or degenerative changes in hip joint, undergoing hip replacement following the fracture of the femoral neck. After the cartilage samples were taken from the resection materials, the DNA polymorphisms in the patients' cartilage samples were tested by Polymerase Chain Reaction (PCR), the serum levels of aggrecanase genes were analyzed with Enzyme-Linked ImmunoSorbent Assay (ELISA). RESULTS: The level of ADAMTS5 and ADAMTS9 genes were found significantly lower as a result of ELISA analysis degenerative arthritis group than the control group (p < 0,05). ADAMTS 1, 4, 8, 15 were similar between the two groups in ELISA analysis (p > 0,05). As a result of quantitative real time RT-PCR analysis, the level of ADAMTS8 mRNA increased 3.5 fold in hip degenerative arthritis group when compared with femoral neck fractures group. ADAMTS1, ADAMTS4 and ADAMTS5 expression levels in hip degenerative arthritis group were decreased 2.5, 2 and 2.5 fold, respectively. ADAMTS9, 15 were found to be similar between two groups. CONCLUSON: As a result of this study on hip osteoarthritis, the ADAMTS8 levels was found to be significantly higher in the end stage of hip osteoarthritis. Unlike similar studies on knee osteoarthritis, ADAMTS1,4,5 levels were found to be lower.

Evaluation of proximal femoral nail-antirotation and cemented, bipolar hemiarthroplasty with calcar replacement in treatment of intertrochanteric femoral fractures in terms of mortality and morbidity ratios.

OBJECTIVES: This study aims to assess the mortality and morbidity rates of patients with intertrochanteric femoral fractures who were performed proximal femoral nail-antirotation (PFNA) or cemented, bipolar hemiarthroplasty with calcar replacement. PATIENTS AND METHODS: A total of 127 patients (42 males, 85 females; mean age 79.2 years; range 55 to 98 years) who were treated due to proximal femoral fracture between January 2008 and January 2011 were compared retrospectively in terms of intraoperative mortality, total mortality, and monthly distribution of mortality rates. Of these 127 patients, 92 (28 males, 64 females; mean age 80.24 years; range 55 to 94 years) who were alive, who achieved at least a 12-month follow-up, and could walk and fulfil daily activities in preoperative period were included in the study. Patients were divided into two groups as PFNA group (n=34) and cemented, bipolar hemiarthroplasty with calcar replacement group (hemiarthroplasty group; n=58). Both groups were compared in terms of duration of operation, requirement for intraoperative blood transfusion, duration of hospital stay, functional outcomes, quality of life, complication and revision rates, and costs of operation. RESULTS: Patients in both groups had the same type of fracture. Bone mineral densitometry results and the type and risk of anesthesia of both groups were similar. No significant difference was detected between two groups in terms of intraoperative mortality, total mortality, and monthly distribution of mortality rates (p>0.05). Mean durations of operation were 54.85 minutes (range 40-110 minutes) and 74.66 minutes (range 55-120 minutes) in the PFNA and hemiarthroplasty groups, respectively. Mean durations of hospital stay were 5.91 days (range 5-12 days) and 9.41 days (range 6-16 days) in the PFNA and hemiarthroplasty groups, respectively. In the PFNA group, durations of operation and hospital stay were shorter and functional results were superior (p<0.05). Requirement for blood transfusion was lower in the PFNA group. CONCLUSION: Both PFNA and cemented, bipolar hemiarthroplasty with calcar replacement are good techniques in treatment of intertrochanteric femoral fractures. Internal fixation may be more appropriate for elderly patients due to shorter duration of operation and lower risk of reoperation.

Eccentric Training as an Adjunct to Rehabilitation Program for Hereditary Multiple Exostoses: A Case Report.

Hereditary multiple exostoses an autosomal dominant skeletal disorder characterized by multiple cartilage-capped benign exostoses that typically occur in the metaphysis of long bones. The prevalence of hereditary multiple exostoses is estimated to be 1 in 50,000. Although, there have been many studies concerning this rare disorder, no research has yet examined the rehabilitation of hereditary multiple exostoses. The case diagnosed with hereditary multiple exostoses referred to our department with several complaints, namely pain, joint limitations, muscle weakness, and functional insufficiency after arthroscopic distal left femur exostoses excision. The aim of this case report was to present effectiveness of eccentric training as an adjunct to rehabilitation program for hereditary multiple exostoses. According to the results, eccentric training after arthroscopic exostoses excision may help reduce pain, increase range of motion, muscle strength, and functional levels in patients with hereditary multiple exostoses.

[Is intraarticular administration of tranexamic acid efficient and safe as systemic administration in total knee arthroplasty? Single center, randomized, controlled trial]. / Total diz artroplastisinde eklem içi tranekzamik asit uygulamasi sistemik uygulama kadar etkin ve güvenilir midir? Tek merkez, randomize, kontrollü çalisma.

OBJECTIVES: This study aims to compare the efficiency and safety of intraarticular and intravenous tranexamic acid administration in patients who were performed primary total knee arthroplasty. PATIENTS AND METHODS: This single center, randomized, controlled trial included 60 patients (8 males, 52 females; mean age 67.8 years; range 53 to 87 years) who were performed primary total knee arthroplasty by three surgeons due to a diagnosis of primary osteoarthritis between January 2015 and June 2015. Patients were separated into three groups. Patients in group 1 and group 2 were administered 2 g intravenous tranexamic acid and 2 g intraarticular tranexamic acid, respectively. Patients in group 3 were not administered tranexamic acid. Pre- and postoperative hemoglobin difference, volume of blood collected in drains, and transfusion rate were analyzed. RESULTS: Compared with the control group, there was no significant difference between group 1 and group 2 in terms of total blood loss from the drain, pre- and postoperative hemoglobin difference, and the need for blood transfusion. CONCLUSION: Both intraarticular and intravenous administrations reduce blood loss and need for transfusion and there is no significant difference between the two techniques in terms of safety.

Popliteal Sciatic Nerve Block in a Pregnant Patient in the Last Trimester.

Although regional anaesthesia is a commonly preferred anaesthesia technique for pregnant patients undergoing non-obstetric surgery, peripheral nerve blocks are relatively less administered. The use of popliteal sciatic nerve block for foot-ankle surgery has been presented for a nulliparous parturient at 32 weeks of gestation scheduled to undergo surgical exploration of an arterial pseudoaneurysm on her right plantar surface due to a penetrating stab injury. Since surgery did not require pneumatic tourniquet, the sciatic nerve was blocked via the popliteal approach with a single shot injection of 30 mL of 0.375% levobupivacaine. The operation and the anaesthesia course were uneventful. In conclusion, popliteal sciatic nerve block was successful and uneventful for a short foot surgery not requiring tourniquet application in a parturient in the last trimester.

An incidental diagnosis of obturator hernia during total hip arthroplasty.

Obturator hernia is a rarely seen disease that frequently affects females and the elderly population. It is clinically characterized with pain generally involving the hip region, and unless suspected, its diagnosis is difficult. Another reason for pain in the hip region and orthopedic surgery is coxarthrosis. The patient should be evaluated in detail radiographically and clinically before surgery. Although preoperative clinical examinations and radiographic findings support the indication for orthopedic surgery performed due to coxarthrosis, the probability of the presence of other pathologies accompanying the present disease should not be forgotten. In this article, we report an obturator hernia incidentally diagnosed in a 65-year-old female patient who was performed total hip arthroplasty due to coxarthrosis.

Humeral head cysts: association with rotator cuff tears and age.

The objective of this study was to retrospectively evaluate the prevalence of the cystic changes at rotator cuff footprint on proximal humeral tuberosities and investigate their relationship with rotator cuff tears and patient age. Magnetic resonance (MR) images of 657 patients who underwent shoulder arthroscopy for treatment of rotator cuff disorders were reviewed to localize the cystic changes at anterior (supraspinatus insertion) and posterior (infraspinatus insertion) aspects of greater tuberosity (GT) and lesser tuberosity (subscapularis insertion). Preoperative MR reports as well as cyst size and locations on MR images were correlated with arthroscopic records of rotator cuff pathology (tear type, size, location and tendon involvement) and patient age. The prevalence of cystic changes was 9.1% (60 patients) in the study population. Anterior GT cysts were found in 56% of patients and were strongly associated with full-thickness (p<.001) and articular-sided partial-thickness rotator cuff tears (p=.02). Posterior GT and lesser tuberosity cysts were found in 27 and 17% of patients, respectively, and were not significantly related to rotator cuff tears, although there was an increased trend of posterior cysts in patients with infraspinatus tears (p=.09). A significant relation was found between patient age and the cyst size (p=.01), while none of the cyst localizations were statistically related to age. Anterior GT cysts were more common in this patient group and demonstrated a strong association with rotator cuff disorders regardless of age. Posterior GT and lesser tuberosity cysts were less common and showed no association with rotator cuff pathology or patient age.

Periosteal adventitia is a valuable bone graft alternative.

BACKGROUND: Periosteal adventitia is believed to consist of fibrous tissue without any regenerative potential. This theory results in the assumption that surgically stripped periosteum which is also adventitial has no bone regeneration potential. We decided to test whether the periosteal adventitia is osteoinductive and whether it is suitable for a commonly faced clinical situation in an animal model. METHODS: This study used 24 femurs from 12 rabbits, which were separated into 3 groups. Lateral femoral condylar cavitary defects were created with a 5 mm drill bit. In group I, the defects were left empty as the control. In group II, the defects were only filled with ceramic graft particles. In group III, the defects were filled with a mixture of ceramic graft particles and autogenous, adventitial, periosteal particles. All animals were sacrificed at the end of the 6th week and were evaluated histologically. RESULTS: The microscopy of 3 different histologists suggested that group III had far superior healing when compared to the control group and group II. The statistical evaluation of the histomorphometrically gathered quantitative results revealed a meaningful increase in woven bone and a decrease in fibrous tissue in group III, confirming the histological analysis. CONCLUSIONS: In this study we observed that the composite graft obtained by mixing ceramics and free adventitial periosteal grafts offers healing potential surpassing both the ceramic-only group as well as the control group. We conclude that adventitial periosteal graft greatly facilitates new bone formation.

Intra-articular variations of the long head of the biceps tendon.

PURPOSE: The long head of the biceps tendon (LHBT) generally runs free through its course in the glenohumeral joint. It can rarely be seen as attached to the joint capsule or the rotator cuff in different patterns. Although these variations are usually considered harmless in the literature, they may occur in conjunction with the labral pathologies. This study was designed to determine their prevalence and investigate their relationship with intra-articular pathologies encountered during arthroscopy. METHODS: Out of a patient population of 671 arthroscopies performed in one center, the data regarding the LHBT variations and labral pathologies were collected retrospectively. RESULTS: Fifty patients (7.4%) of this total population were included as possible LHBT variants. Categorized into seven groups ranging from the simple vinculum, cord, and pulley types to the synovial tunnel types partially or totally fused to the capsule and to more complex types adherent to the capsule or the rotator cuff, their association with the labral pathologies was analyzed. The labral pathology prevalence was significantly higher in this group of 50 patients with LHBT variants compared to the total population (32 vs. 13%; P < 0.001). In the pulley-type variant group, the labral pathologies were also encountered at a significantly higher rate than the total population (62.5%; P = 0.026). CONCLUSION: The prevalence of embryological variations of the biceps tendon may be higher than common presumptions, and a particular type of these variants displays an increased association with labral pathologies.

Validation of the VISA-A questionnaire for Turkish language: the VISA-A-Tr study.

OBJECTIVES: To evaluate the validity and reliability of the Turkish version of the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire for patients with Achilles tendinopathy. DESIGN: Fifty-five patients with a diagnosis of Achilles tendinopathy and 55 healthy subjects were included in the study. VISA-A questionnaires were translated and culturally adapted into Turkish. The final Turkish version (VISA-A-Tr) was tested for reliability on healthy individuals and patients. Tests for internal consistency, validity and structure were performed on 55 patients. RESULTS: The VISA-A-Tr showed good test-retest reliability (Pearson's r=0.99, p<0.001). The patients with Achilles tendinopathy had a significantly lower score (p<0.001) than the healthy individuals. The VISA-A-Tr score correlated significantly with the Stanish tendon grading system (Spearman's r=-0.86; p<0.001). CONCLUSION: The VISA-A-Tr is a valid and reliable tool for evaluating the severity of Achilles tendinopathy.

Evaluation of the medial longitudinal arch: a comparison between the dynamic plantar pressure measurement system and radiographic analysis.

OBJECTIVES: The measurement of the medial longitudinal arch (MLA) of the foot is a controversial issue in orthopedics. Several methods have been developed to define and determine the MLA, but none of them are universally accepted. The purpose of this study was to compare some statically obtained radiographic angles with the dynamic plantar pressure distribution measurement system for the evaluation of the MLA in healthy individuals. METHODS: A total of 95 subjects (72 females, 23 males; mean age 37.8 years; range 11 to 85 years) were retrospectively evaluated. All the subjects were referred to the pedobarography laboratory for varying causes, had foot radiographies, and were evaluated as having normal feet. On standard lateral weight-bearing radiographs of the foot, the lateral talocalcaneal angle, talo-first metatarsal angle, talohorizontal angle, and calcaneal pitch angle were measured. The plantar pressure distribution was measured by the EMED-SF system. To evaluate the MLA, the arch index method was used. The arch index was calculated by the ratio of the pressure area of the midfoot to the sum of the forefoot, midfoot, and the hindfoot areas. Correlations between the radiographic angles and the arch index were analyzed by the Pearson correlation test. RESULTS: The mean values of the lateral talocalcaneal angle, talo-first metatarsal angle, talohorizontal angle, and calcaneal pitch angle were 43.2, 7.2, 29.5, and 41 degrees, respectively. The mean value of the arch index was 0.12 (range 0.04 to 0.17). There was no significant correlation between the arch index and gender (r=-0.10, p>0.05). The talo-first metatarsal (r=0.38) and talohorizontal (r=0.19) angles were found to be in significant correlation with the arch index (p<0.05), whereas the talocalcaneal (r=-0.16) and calcaneal pitch (r=-0.10) angles did not show correlation with the arch index (p>0.05). CONCLUSION: The arch index method is a simple and reproducible pedobarographic measurement for the evaluation of the MLA. However, the angles measured on statically obtained radiographs and showing correlations with the arch index may give similar results concerning the MLA. Both static and dynamic methods can be utilized in the evaluation of the MLA.

Double plate osteosynthesis provides better biomechanical stabilization than double tension band technique in distal humerus fractures.

OBJECTIVES: In this study we evaluated the stability and effectiveness of the double tension band osteosynthesis technique compared to the double plate osteosynthesis technique used for fixation of distal humerus fractures. MATERIALS AND METHODS: The study was performed on two groups, and in each group eight cadaveric, elderly (mean age 70-80) human humeri was used. An osteotomy was performed in the supracondylar region using a manual saw. The first group (group 1) was fixed with double 3.5 mm reconstruction plates, while the second group (group 2) was fixed with the double tension band technique, using crossing Kirschner wires. The osteotomy was designed so that the distal fragment would allow only a single screw per plate. The constructs were evaluated using a material testing machine. A linear non-cyclic load was applied until the failure of the constructs. The force which produced a 3 mm gap (3 mm gap strength), as detected visually with the aid of operating loupes, and the maximum load prior to failure of the fixation (maximum force) were measured from all tests. RESULTS: The mean value for the 3 mm gap strength was 1356.29+/-226.97 N for group 1 and 882.63+/-305.21 N for group 2. The mean value of the maximum load strength was 1487.13+/-298 N for group 1 and 1232+/-107.62 N for group 2. There were significant differences in 3 mm gap strengths of the two groups (p=0.005). There was also a significant difference in the maximum load between the two groups (p=0.016). CONCLUSION: Double plate osteosynthesis technique is superior to double tension band osteosynthesis for the fixation of distal humerus fractures.

Effects of a single application of extractum cepae on the peritendinous adhesion: an experimental study in rabbits.

Peritendinous adhesion is an important cause of poor functional outcome after flexor tendon repair. The objective of this study was to investigate the effect of a single intraoperative application of extractum cepae, an extract of dietary onion, on the peritendinous adhesion, using a rabbit model of flexor tendon injury. The first, second, and third digits of the right hind paw of 18 rabbits were used for tendon operations. A standard partial division of the synovial sheath and flexor tendon was done at zone II to stimulate the adhesion formation. In the treatment group (n = 9 rabbits, 27 tendons), the flexor tendon sheath was treated with 50 mg/mL of extractum cepae which was applied locally and allowed to infiltrate for 5 minutes, the skin was sutured without suturing the sheath and the tendons. The same operation was done for the control group (n = 9 rabbits, 27 tendons) and 1 mL of normal saline solution was applied locally. Biomechanical and histologic evaluations of the specimens were done after 3 weeks. Tendons from the first toes were used for biomechanical studies. The second and third toe tendons were used for histopathologic evaluation. We have compared the peritendinous adhesions and the ultimate forces in the control and treated tendons. There were no statistically significant differences between the 2 groups with respect to the ultimate loads. Adhesion formation was absent in 1 tendon (5.5%), slight in 8 (44.4%), moderate in 6 (33.3), and severe in 3 tendons (16.7%) in the extractum cepae treated group (n = 18); while in the control group (n = 18), it was absent in 1 tendon (5.5%), slight in 1 tendon (5.5%), moderate in 3 (16.6%), and severe in 13 (72.4%) tendons. There was a significant reduction (P = 0.01) in the peritendinous adhesion in the treated group comparing to the control group. The problem of adhesion formation may be minimized using a single intraoperative application of extractum cepae.

Osteochondritis dissecans with subchondral bone cyst of the femoral condyle: a novel surgical technique of treatment.

Osteochondritis dissecans (OCD) with a large subchondral bone cyst (SBC) is not common. The treatment of this lesion may be unsuccessful with conventional techniques. A novel surgical technique is described for the treatment of OCD with SBC of the femoral condyle. Modified osteochondral multiple autograft transfer following extraarticular curettage and bone grafting of SBC is a promising technique.

[Comparison of radiation exposure times in the treatment of pediatric supracondylar humeral fractures with open-closed reduction and internal fixation]. / Cocuklarda suprakondiler humerus kiriklarinin açik-kapali redüksiyon ve internal tespitle tedavisinde radyasyon sürelerinin karsilastirilmasi.

OBJECTIVES: We compared open reduction-internal fixation (ORIF) and closed reduction-internal fixation (CRIF) with respect to operation and radiation exposure times in the treatment of displaced supracondylar humeral fractures in children. METHODS: This retrospective study included 124 children (76 boys, 48 girls) who underwent surgical treatment for displaced supracondylar humeral fractures (Gartland type 3). Of these, 52 patients (mean age 7.5 + or - 2.8 years) underwent ORIF, and 72 patients (mean age 6.1 + or - 2.5 years) underwent CRIF. Operation and fluoroscopy times were recorded in both groups. Final assessments included range of motion, varus- valgus angulation, neurovascular findings, and cosmetic appearance. Functional and cosmetic results were assessed using the criteria of Flynn et al. after a mean follow-up period of 49.3 + or - 18.6 months and 50.4 + or - 17.9 months in the ORIF and CRIF groups, respectively. RESULTS: Radiographical union was obtained in all the patients within six weeks postoperatively. The two groups did not differ with respect to functional and cosmetic results (p>0.05), with excellent-good results accounting for 90.3% in the CRIF group, and 86.6% in the ORIF group. The mean operation times were 44.2 + or - 12.6 and 28.3 + or - 8.2 minutes, and the mean fluoroscopy times were 36.0 + or - 15.3 and 11.7 + or - 4.5 seconds, in the CRIF and ORIF groups, respectively, both being significantly longer in the former (p=0.000). CONCLUSION: As extended fluoroscopy use increases radiation exposure, ORIF sems to be more convenient for the treatment of displaced supracondylar humeral fractures.