The effect of oral hydroxychloroquine on chondral defect: An experimental study.

OBJECTIVES: This study aims to evaluate the time- and dose-dependent effects of oral hydroxychloroquine (HCQ) on focal full-thickness knee chondral defect healing in a rabbit model. MATERIALS AND METHODS: Cartilage defects of 4x4 mm2 were created on both medial femoral condyles of 24 New Zealand rabbits. The rabbits were divided into six groups (A-F) according to HCQ administration and sacrifice time: A (three-week control) and B (six-week control) received no additional interventions; C (20 mg/kg HCQ, three weeks); D (20 mg/kg HCQ, six weeks); E (40 mg/kg HCQ, three weeks); and F (40 mg/kg HCQ, six weeks). Osteochondral specimens were evaluated macroscopically, histologically, and immunohistochemically. The terminal deoxynucleotidyl-transferase (TdT)-mediated dUTP nick end labeling (TUNEL) method was used to detect apoptotic cells. RESULTS: The International Cartilage Repair Society (ICRS) scores were significantly higher in the experimental groups than in the controls (p<0.001). The Wakitani scores in Group D showed a significant improvement compared to those in Group B (p<0.01). The 20 mg/kg HCQ treatment groups showed better recovery than the controls (p<0.01). High-dose HCQ (40 mg/kg) treatment significantly reduced the intensity of collagen type 2 immunoreactivity compared to that in the groups receiving 20 mg/kg of HCQ (p<0.01). Collagen type 2 expression in Group F was significantly lower than that in Group D (p<0.01). There were more TUNEL-positive cells in the repair sites of Groups E and F than in the lower-dose experimental groups and untreated experimental groups (p<0.001). CONCLUSION: A low dose of HCQ improved cartilage repair, while higher doses of HCQ exerted a negative effect on cartilage regeneration in rabbits. In the presence of defective cartilage, the use of HCQ at an appropriate dose and time is important for cartilage health.

Effects of anterior cruciate ligament rupture and reconstruction on sexual activity of male patients.

OBJECTIVES: This study aims to investigate the impact of anterior cruciate ligament (ACL) injury and its reconstruction on men's sexual functions. PATIENTS AND METHODS: Between February 2016 and November 2019, a total of 27 sexually active male patients (mean age: 33.7±4.3 years; range, 26 to 40 years) who were operated for ACL injury at least six months after trauma were retrospectively analyzed. Erectile function was assessed using the International Index of Erectile Function questionnaire (IIEF) and knee function was evaluated by using the International Knee Documentation Committee (IKDC) Scoring System, Lysholm Knee Scoring Scale, and Tegner Activity Score. Sexual and functional questionnaires were applied to evaluate three different periods retrospectively. These periods were as follows: the period before an ACL injury (Period I); the period in which the patient suffered from an ACL injury, but not operated (Period II), and the period after the ACL reconstruction (Period III). RESULTS: There was a statistically significant difference in the comparison of knee function scores according to three different periods. Sexual function scores were significantly different between Periods I and II, and between Periods I and III. However, although the IIEF value was higher in Period III than in Period II, no statistically significant difference was observed. A moderate correlation was found between the sexual functional scores of IIEF and IKDC scores. CONCLUSION: Our study results suggest that ACL injury affects sexual functions adversely. The change in sexual functions after ACL surgery depends on the success of surgery. While deciding on the treatment of ACL injury, the patient's sexual life should be questioned along with his expectations.

Fracture lines and comminution zones in acetabular fractures based on three dimensional computed tomography.

PURPOSE: To characterize the fracture patterns of acetabular fractures and create fracture maps and comminution zones based on three-dimensional (3D) computed tomography (CT) images. METHODS: Sixty-eight computed tomography images of 67 patients (47 male [70.1%] and 20 female [29.9%], mean age: 45.2 ± 17.2 [range, 18-85 years] with the diagnosis of intra-articular acetabulum fracture were analyzed. Individual fracture lines were drawn and superimposed to a healthy acetabular template according to Judet-Letournel and simplified fracture classification systems. Fracture line, comminution zone, and heat maps were created using the computed tomography mapping technique. RESULTS: Fracture lines were distributed mainly in a horizontal and oblique orientation, which concentrated in the anteroinferior part of the joint in anterior fractures. Posterior fractures mostly had an oblique orientation, which lied between the acetabular dome and middle part of the posterior wall. In complex fractures, fracture lines were concentrated just above the cotyloid fossa, acetabular dome, and posterosuperior part of the acetabulum. The most common comminuted zones were around the central area of the articular surface and the anterior wall in anterior fractures, between the cotyloid fossa and dome in complex fractures, and the upper half posterior wall. CONCLUSION: Fracture patterns and comminution zones of acetabular fractures displayed certain characteristics. Some areas had higher comminution zones, and some areas remained intact in repeatable fracture patterns. These results may help surgeons in fixing acetabular fractures, designing new implants, and placement of acetabular component while performing THA after acetabular fractures.

Assessment of clinical, biochemical, and radiological outcomes following intra-articular injection of Wharton jelly-derived mesenchymal stromal cells in patients with knee osteoarthritis: A prospective clinical study.

The aim of the present study was to perform clinical, biochemical, and radiological evaluation of the efficacy of mesenchymal stem cells derived from Wharton jelly (WJ) present within the human umbilical cord in the treatment of knee osteoarthritis. Between 2018 and 2019, 10 patients with knee osteoarthritis for whom the conservative treatment was not beneficial were included in the study. Patients were clinically, radiologically, and biochemically evaluated before treatment initiation. Thereafter, the patients were intra-articularly injected using a solution containing 1 × 108 WJ-derived MSCs. Evaluations were performed on day 21 (V1) and 42 (V2) and month 3 (V3), 6 (V4), and 12 (V5) after the procedure. At 1-year post-injection, visual analogue scale, Western Ontario and McMaster Universities Osteoarthritis Index, and Lequesne scores of patients were lower than those observed during the initial evaluation, whereas the mean 36-Item Short Form Health Survey score was higher. Cartilage thicknesses were found to be increased in all regions except in the medial femur, medial posterior femur, lateral posterior femur, and lateral posterior tibia regions in magnetic resonance imaging. A significant increase was observed in tumor necrosis factor-alpha, interleukin-1ß, adiponectin, resistin, and interleukin-6 levels compared with pre-injection values. The leptin levels at 6-month and 1-year controls were lower than the pre-injection levels, and the decrease observed at 6 months was significant. In patients with knee osteoarthritis, intra-articular WJ-derived MSC injection causes significant pain reduction, satisfactory functional improvement, and increased patient satisfaction following a 1-year follow-up. These clinical improvements were supported by magnetic resonance images, along with changes in adiponectin and leptin levels in synovial fluid. Level of evidence: IV.

The Influence of Component Rotational Malalignment on Early Clinical Outcomes in Total Knee Arthroplasty.

Background The most important cause of patient dissatisfaction following total knee arthroplasty (TKA) is pain. Component rotation is an important factor in the clinical success of TKA. This study aims to determine component rotational errors in patients with mobile- and fixed-bearing polyethylene inserts after TKA and also to evaluate the effect of possible malrotations on clinical outcomes. Methods Seventy-five knees from sixty-six patients who underwent TKA were evaluated retrospectively. The patients were divided into two groups according to whether they received a mobile-bearing polyethylene insert (group 1, n = 48) or a fixed-bearing polyethylene insert (group 2, n = 27). The Hospital for Special Surgery (HSS) score, the Western Ontario and McMaster Universities Arthritis Index (WOMAC), the Lysholm Knee Scoring Scale, and the Oxford Knee Score were used for the clinical evaluation of the patients. The rotational state of the components was evaluated by computed tomography. Results The HSS, WOMAC, Lysholm, and Oxford clinical scores were not significant between the two groups (p > 0.05). The effect of femoral versus tibial component rotational deviation on clinical scores was not significant between the two groups (p > 0.05). Component rotational differences did not have a significant effect on the degree of knee flexion and extension between groups (p > 0.05). When the combined rotations of the components were compared with the clinical scores of function, no significant difference was detected between groups (p > 0.05). In addition, no significant difference between the operated sides of the patients and the combined component internal rotations was found (p > 0.05). Conclusion Although component rotation is an important factor in the clinical success of TKA, the current study did not find a clear association between the clinical results after TKA and the internal rotation of components. Component internal rotation alone is not an important predisposing factor for pain development after TKA. We believe that this may be attributed to the significant effects of patient expectation, which is often ignored, on clinical scores.

Relationship Between Neutrophil/Albumin Ratio and Early Mortality After Major Lower Extremity Amputation.

Introduction Diabetic foot infection is a condition that affects the patient's life, may cause limb loss, and has a high mortality. Too many parameters were used for predicting early mortality but the gold standard method wasn't described. Neutrophil lymphocyte ratio (NLR) is universally accepted as a predictive value for amputation-free survival and mortality. NLR increases due to inflammation-induced neutrophilia and lymphopenia related to cortisol-induced stress. Increasing in the neutrophil albumin ratio is expected due to decreasing albumin levels because albumin is a negative acute-phase reactant. The aim of this study is to investigate the sensitivity and value of the neutrophil albumin ratio (NAR) for early mortality after major lower extremity amputation (LEA). Methods  Following the approval of the ethics committee, 87 patients who underwent major LEA between May 2018 and May 2020 were analyzed for the study. White blood cell (WBC), neutrophil, lymphocyte, C-reactive protein (CRP), creatinine, albumin, platelet, and hemoglobin values on the day prior to surgery were recorded. NLR was calculated as the ratio of neutrophil count to lymphocyte count, NAR as the ratio of neutrophil count to albumin value, CRP/albumin ratio (CAR) as the ratio of CRP value to albumin value, and platelet lymphocyte ratio (PLR) as the ratio of platelet count to lymphocyte count. Each parameter was also recorded in the postoperative second week. Results Of the patients included in the study, 52 were men (59.8%) and 35 were women (40.2%). It was determined that 29 of 87 patients (33.3%) died within the first year. The relationship between post-operative NAR value and early mortality is examined. The area under the curve was calculated as 0.873. When the cut-off value was applied as 0.265, the sensitivity was found as 88% and specificity as 76%. Conclusions Higher neutrophil/albumin ratio after lower extremity amputation was associated with early mortality after extremity amputation. This parameter can help predict mortality. The cut-off value was determined as 0.265, the sensitivity was found as 88%, and specificity as 76%.

Failure of Major Upper Extremity Replantation Due to COVID-19-Related Arterial Thrombosis.

Coronavirus disease of 2019 (COVID-19), caused by the new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that emerged in Wuhan, was declared a pandemic by the World Health Organization. COVID-19 has many different clinical manifestations. One of them is arterial hypercoagulopathy. Although its mechanism is not fully explained, acute thrombosis and thromboembolism can be seen in patients. In this study, we present a case who was amputated due to the development of arterial thrombosis on the 10th day following infection with coronavirus, despite successful replantation after traumatic above-elbow amputation. After replantation on the seventh day, it was learned that the patient's husband was positive for COVID-19 and had come to visit the patient. For this reason, we performed reverse transcription polymerase chain reaction (RT-PCR) to confirm the patient's COVID-19 status. We found that the patient, who was asymptomatic, was positive by RT-PCR for COVID-19. On the 10th day after the operation, it was observed that the blood circulation of the replanted extremity was impaired, although it had been perfect until that day. Emergency embolectomy and vascular reanastomosis were planned for the patient. Although we generally observe thrombosis at an end-to-end anastomosis site, massive axillary arterial thrombosis was detected at the proximal end of the vascular anastomosis. Upon development of tachycardia, hypotension, and metabolic acidosis after embolectomy and vascular reanastomosis, the decision was made to amputate the replanted limb to reduce the risk of life-threatening complications. To our knowledge, this is the first such COVID-19-related complication on upper extremity replantation in the literature.

Relationship between Serum YKL-40 Level and Forearm Arterial Patency after Repair.

BACKGROUND: The study aimed to assess the effects of serum YKL-40 level on patency at the repair site in patients who underwent arterial repair at the level of the forearm. METHODS: The study included 58 subjects, including 29 patients (aged 18-50 years) who had ulnar or radial artery injury secondary to cut injury to wrist between June 2015 and November 2019 and no comorbid disease and 29 age- and sex-matched healthy controls. The vascular patency was assessed using Doppler sonography in patients who underwent arterial repair at the level of the forearm. The patients were defined as flow failure if the blood flow was ≤50%, and sufficient flow if the blood flow was >50% of those in the synonymous artery on the intact extremity. The YKL-40 level differences in the patient and control groups were compared to those in the sufficient and insufficient flow groups. RESULTS: The patients were stratified into 2 groups based on the presence of sufficient flow. The mean YKL level was 11.96 ± 8.87 in the sufficient flow groups, whereas it was 32.22 ± 15.43 in the insufficient flow groups (p= 0.038). Besides, it was found that each unit of increase in the YKL-40 level increased the likelihood of having flow failure by 1.128. CONCLUSION: Based on our results, it was observed that over-expression of the YKL-40 level has adverse effects on patency following arterial repair.

A Comprehensive Coronal and Axial Bone Dimension and Cartilage Thickness Evaluation of the Distal Humerus: Age and Sex Differences.

OBJECTIVE: There are limited data on bone dimension and cartilage thickness of the distal humeral articular surface. This study aimed to evaluate sex- and age-related bone dimension and cartilage thickness differences and assess the effect of cartilage thickness on distal humeral shape. DESIGN: Elbow magnetic resonance images of 180 healthy participants were evaluated. Cartilage thicknesses of the trochlea and capitellum were measured at 19 points using coronal and axial images. In addition, bone diameters were measured from the flexion-extension axis to the 19 points on the coronal and axial magnetic resonance images. Sex differences were evaluated, and the correlation between age and measurement parameters was assessed. RESULTS: Significant sex differences regarding the diameters of the axial trochlear bone, coronal lateral trochlear bone, and medial capitellar bone, cartilage thickness at the apex of the lateral trochlear ridge in the axial and coronal plane and at the most lateral point of the capitellar articular surface in the axial plane were observed. A negative correlation was observed between age and axial plane trochlear bone dimensions and between age and coronal plane lateral trochlear and medial capitellar bone dimensions. No significant correlation was found between cartilage thickness and bone dimensions. CONCLUSIONS: Bone dimension and cartilage thickness at the distal humerus vary according to sex and age. The data could be used in the donor site selection and graft preparation while osteochondral autograft transfer and allograft transplantation, and in the development of gender-compatible hemiarthroplasty implants.

Lateral and patellofemoral compartment osteoarthritis progression after medial unicompartmental knee arthroplasty: A five- to 10-year follow-up study.

BACKGROUND: The purpose of the study was to evaluate lateral and patellofemoral osteoarthritis (OA) progression after medial unicompartmental knee arthroplasty (UKA) and identify factors affecting the progression that were not identified previously. METHODS: We evaluated 146 patients who underwent medial UKA between 2009 and 2014. Kellgren-Lawrence grading of lateral and patellofemoral OA was performed on preoperative and final follow-up knee radiographs. Radiographic and clinical characteristics, SF-36, and Oxford knee scores were compared between the OA progressed and non-progressed groups. Risk factors for lateral and patellofemoral OA progression were evaluated. RESULTS: The lateral OA progressed and non-progressed groups significantly differed in side, preoperative flexion contracture, preoperative joint line convergence angle, postoperative tibiofemoral angle, insert size, revision status (P < 0.05), and the patellofemoral OA progressed and non-progressed groups significantly differed in age, pre- and postoperative flexion contracture, postoperative tibiofemoral angle and pre- and postoperative patellofemoral OA grade (P < 0.05). At the final follow-up, Visual Analogue Scale, Oxford Knee Scores, and SF-36 sub-scores were significantly better in the lateral OA non-progressed group (P < 0.001). Dominant leg (odds ratio (OR): 2.759), insert size (>4, OR: 2.219), revision status (+, OR: 6.692), and postoperative tibiofemoral angle (>5.5°, OR: 1.177) were independent risk factors for lateral OA progression, whereas age (>60 years, OR: 3.222), preoperative patellofemoral OA grade (>1, OR: 2.085), and postoperative flexion contracture (>10°, OR: 1.919) were those for patellofemoral OA progression. CONCLUSIONS: Mild radiographic progression of 1 KL grade is frequently seen five to 10 years after medial UKA. Postoperative outcomes are significantly affected by lateral compartment OA progression but not by patellofemoral OA progression.

Effect of kirenol on the interaction between the WNT/ß-Catenin and RUNX2/TCF/LEF1 pathways in fracture healing in vivo.

OBJECTIVE: This study aimed to determine the effects of a natural diterpenoid, kirenol, on fracture healing in vivo in an experimental rat model of femur fracture and investigate its potential mechanism of action via the Wnt/ß-catenin pathway. METHODS: In this study, 64 male Wistar albino rats aged 5-7 weeks and weighing 261-348 g were randomly divided into 8 groups from A to L, with eight rats in each group. Standardized fractures were created in the right femurs of the rats and then fixed with an intramedullary Kirschner wire. Four experimental groups were administered 2 mg/kg/day kirenol (Groups C and G) and 4 mg/kg/day (Groups D and H) kirenol by oral gavage.Thereafter, the animals were sacrificed at two time points as follows: on the 10th day (Groups B, C and D) and on the 21st day (Groups F, G and H) after the surgery; fracture healing in each group was assessed radiologically and histopathologically. The Radiographic Union scale of tibia fracture scoring system was used in the radiological examination; callus volume and density were measured using computed tomography. In the histopathologic examination, the scoring system described by Huo et al. was used. Additionally, the mechanism of action was evaluated based on the analyses of protein expression of Wnt3a, LRP5, TCF-LEF1, ß-catenin, and Runx-2 proteins using western blot analysis. RESULTS: Among the animals sacrificed on the 10th day after the surgery, the highest histopathological and radiological scores were observed in Group D (p<0.05). Furthermore, the callus density (p<0.05) was highest in Group D. Among the animals sacrificed on the 21st day, the highest histopathological and radiological scores were found in Group H, although the differences among the groups were not significant (p>0.05). The callus volume and density were the highest in Groups G and H, respectively, although the differences among groups were not significant. CONCLUSION: Kirenol may improve fracture healing in a dose-dependent manner with the early activation of the Wnt/ß-catenin pathway and the activation of the Runx-2 pathway.

Mid-term functional, clinical, and radiological outcomes with factors affecting revision of mobile-bearing medial unicompartmental knee arthroplasty.

BACKGROUND: To evaluate and compare the clinical and radiological outcomes of patients subjected to medial unicompartmental knee arthroplasty (UKA). METHODS: The study included 146 knees of 115 consecutive medial UKAs patients with a minimum five-year follow-up. Pre- and postoperative functional and clinical outcomes were measured using the Visual Analog Scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford Knee Score (OKS), American Knee Society Score (AKSS-O), knee range of motion (ROM), and Short-Form Health Survey (SF-36). The Kellgren-Lawrence osteoarthritis (OA) grading system was used for the evaluation of the OA status. The joint line convergence angle (JLCA) of the operated and contralateral knee, the tibiofemoral coronal angle (TFCA), and the tibial slope angle were used in the radiological evaluation. RESULTS: The mean age of patients was 58.8 ±â€¯7.0 years. The mean follow-up period was 7.41 ±â€¯1.54 years. Good to excellent functional outcomes were obtained according to VAS, WOMAC, OKS, AKSS-O, and SF-36 scores. Insert dislocation was the main reason for revision surgery (nine patients, 90%). Preoperative body mass index (BMI), postoperative BMI, American Society of Anesthesiologists (ASA) Score, postoperative knee flexion contracture, mean increase in postoperative medial joint space (PMJS) height, and OA progression were found to affect the revision status. CONCLUSIONS: Good to excellent functional, clinical, and radiological outcomes were obtained with medial UKA at a minimum follow-up of five years. Differences in preoperative and postoperative radiological parameters except an increase in PMJS height had no impact on revision status.

Midterm Results of Tension Band Wiring Technique for Acute Rockwood Type III Acromioclavicular Joint Dislocation.

Background The aim of this study was to evaluate the clinical and radiological results of patients with acute type III Rockwood acromioclavicular joint (ACJ) dislocation treated surgically by employing tension band wiring. Methods The study included 24 patients with traumatic type III ACJ dislocations according to the Rockwood classification. The clinical and radiological outcomes of patients were assessed at the final follow-up visit. Implant failure and reduction loss were assessed using radiographs, whereas the Constant-Murley scoring system was used to assess the patients clinically. Results The mean follow-up period was 3.5 ± 1.3 years (range: 1-6 years). The mean age of the patients was 41.8 ± 11.7 years (range: 19-64 years) and the mean length of hospital stay was 2.3 days (range: 1-6 days). The fixation material was removed postoperatively at an average of 7.2 ± 9.9 months (range: 3-40 months). At the end of the follow-up period, the mean Constant-Murley score was 72.5 ± 12.8 (range: 50-90). The ACJ reduction was stable in 13 (54.2%) patients. Residual subluxation was detected in 11 (45.8%) patients. Distal clavicular osteolysis was noted in six (25%) patients. Acromioclavicular osteoarthritis was detected in five (20.8%) operated shoulders on follow-up radiographs. During the follow-up, Kirschner-wire migration and breakage occurred in four (16.6%) and seven (29.1%) patients, respectively. Conclusions This study showed that surgical treatment with the tension band wiring method provided functionally satisfactory results even if complications developed because of the presence of implants. Independent of age, we can recommend it as the primary treatment method for patients who do not have very high expectations regarding their shoulder function. Additionally, we think that reducing the duration of implant retention will reduce the incidence of complications.

Is there an association of hematopoietic stem cell and endothelial progenitor cell markers with maturation in forearm arterial repair?

OBJECTIVES: This study aims to assess the effects of the hematopoietic stem cells and endothelial progenitor cells in peripheral blood and monocyte cluster of differentiation (CD) 34, CD133 and CD309 expression levels on maturation at the repair site in patients who underwent forearm arterial repair. PATIENTS AND METHODS: This prospective study included 30 patients (23 males, 7 females; mean age 28.9±1.8 years; range, 18 to 49 years) with a well-defined cut at the wrist due to a stabbing injury but no comorbid condition who presented to the emergency department of our hospital between November 2014 and November 2017. Vascular patency was assessed by Doppler sonography in patients who underwent forearm arterial repair via micro-vascular techniques. The relationships between patency and hematopoietic stem and endothelial progenitor cell markers such as CD34, CD133 and CD309 were assessed by flow cytometry. RESULTS: The patients were divided into two groups according to presence of sufficient flow in the arteries repaired. The mean CD34 expression level was 72.09±3.00 in the group with maturation whereas it was 54.64±7.34 in the group without maturation, indicating a statistically significant difference (p<0.05). In addition, the likelihood of sufficient flow was increased by 1.075 per one unit increase in CD34 level. Resistive index values were significantly lower in the group with maturation and CD34 level was predictive for maturation of arterial repair. CONCLUSION: In the present study, the findings demonstrated that high CD34 expression level has favorable effects on maturation after arterial repair.

Diffusion tensor imaging of the median nerve healing. Preliminary results.

AIMS: This study aimed to examine the correlation between DTI, clinical assessment, and electromyography results in patients who underwent primary median nerve repair. METHODS: Ten patients who underwent primary repair of the complete median nerve transection were included. Study assessments were performed on both the traumatized and non-traumatized extremities and patients were followed up for a minimum duration of 11 months. Clinical assessments, (Tinnel test, static 2-point discrimination test, motor and quality of life assessments), electromyography and DTI were performed. RESULTS: None of the clinical or electromyographic parameters correlated significantly with any of the diffusion tensor imaging parameters, i.e. fractional anisotropy (FA) or apparent diffusion coefficient (ADC) (p>0.05 for all). In addition, The Disabilities of the Arm, Shoulder and Hand (DASH) scores did not correlate with either FA (r=0.55, p=0.098) or ADC (r=0.40, p=0.260) values. However, Tinnel positive cases (n=3) had lower relative FA when compared to Tinnel negative cases (n=7) (-0.11±0.19 vs. 0.05±0.04, p=0.033). CONCLUSION: Our findings do not support the presence of relations between DTI parameters and electromyographic or most of the clinical parameters. Further MRI studies with larger numbers of patients with complete transection of the median nerve using the novel imaging parameters are warranted. KEY WORDS: Diffusion Tensor Imaging (DTI), Electromyography (EMG), Median nerve, Nerve injury, Nerve repair.

Unusual combination of femoral head dislocation associated acetabular fracture with multipart femoral fractures: Case report.

INTRODUCTION: Traumatic hip dislocation associated with femur intertrocanteric fracture is a rare and severe injury and it frequently occurs following a high energy trauma, Associated acetabular fractures with this injury are even more rare and potentially cause devastating consequences including avascular necrosis of the femoral head and subsequent early secondary osteoarthritis of the hip joint. PRESENTATION OF CASE: In this case report, we present a 20year old polytraumatized patient with traumatic hip dislocation associated with ipsilateral acetabulum fracture and simultaneous fractures of the ipsilateral femur. DISCUSSION: Traumatic hip dislocation associated with femur intertrochanteric fracture is a rare and severe injury and it frequently occurs following a high energy trauma. In polytraumatized patients, musculoskeletal injuries are the most common lesions requiring surgical intervention frequently presenting challenging scenarios in terms of functional outcome and quality of life. Osteonecrosis of the femoral head is a serious and unpredictable complication that may occur after displaced femoral neck fracture and traumatic hip dislocation due to the disturbed blood supply of the femoral head. CONCLUSION: A staged treatment strategy may be useful managing an unstable polytraumatized patient or a patient who requires prolonged transfer to receive definitive care.

Atraumatic diplaced bilateral femoral neck fracture in a patient with hypophosphatemic rickets in postpartum period: A missed diagnosis.

INTRODUCTION: Simultaneous bilateral femoral neck fracture is an uncommon condition. There are very few cases reported in the literature and most of these cases have underlying bone pathologies such as renal osteodystrophy and osteomalacia. In some cases bilateral femoral neck fractures occur due to generalized seizures or high-energy trauma. PRESENTATION OF CASE: In this case report "atraumatic bilateral femoral neck fracture in a 26year old woman in postpartum period with hypophosphatemic rickets disease" is presented. DISCUSSION: Femoral neck fractures are more frequently seen in elderly because of the reduction of bone quality and developing osteoporosis. In the literature generalized epilepsy, osteomalacia, hypovitaminosis D and chronic renal failure are shown as facilitating causes of bilateral femoral neck fractures. In patients without any additional pathology electric shock, electroconvulsive therapy, and high-energy trauma can lead to femoral neck fractures. In our patient there was also an underlying pathology, she has been followed due to autosomal recessive hypophosphatemic rickets disease since she was one year old. In the treatment of bilateral femoral neck fractures open/closed reduction internal fixation or hip arthroplasty are applied. CONCLUSION: For patients with bone metabolic diseases and/or the patients in pregnancy and postpartum period, preventive measures should be increased to reduce the risk of pathologic fracture. Admitting to the hospital physicians must be more careful about detecting fractures in these patients.