Isokinetic performance and function are similar after total hip arthroplasty applied with a posterior or anterolateral approach: a randomised controlled trial.

BACKGROUND: There are ongoing debates on the effects of surgical approach on outcome after total hip arthroplasty (THA). It was hypothesised that with the anterolateral approach, trauma to the abductor arm can occur and related detrimental effects can diminish the postoperative outcomes. In this first randomised controlled trial in the literature on this subject, isokinetic performance and patient-reported functional outcomes were evaluated in patients undergoing THA with a posterior approach (PA) and an anterolateral approach (ALA). METHODS: A total of 48 patients scheduled to undergo THA were randomised to ALA or PA groups. The patients were evaluated preoperatively and at 6 and 12 months postoperatively, with flexion, extension and abduction strength measurements and the Harris Hip Score (HHS). The physiatrist performing isokinetic tests and the patients were blinded to the study groups. RESULTS: Both groups were similar in respect of age, body mass index (BMI), gender and preoperative isokinetic performance and HHS. Both groups demonstrated similar isokinetic performance (p < 0.05) and there was no difference in HHS (p < 0.05) at the 6- and 12-months follow-up evaluations. CONCLUSION: Although there is concern about potential abductor muscle damaging during ALA, the results of this randomised controlled study demonstrated that ALA can produce similar isokinetic performance and functional outcome to PA at 6 and 12 months, despite the close proximity to the abductor arm. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT04640740 (retrospectively registered).

Radiation exposure during proximal femoral nailing: Traction table versus conventional table.

OBJECTIVES: The aim of this study was to compare radiation exposure of the patient during the closed reduction and proximal femoral nailing (PFN) of the trochanteric region fractures of the proximal femur using a traction table (TT) or a radiolucent table (RT) in the supine position. PATIENTS AND METHODS: Between June 2019 and December 2020, the study included 42 patients (19 males, 23 females; mean age: 81.2±9.5 years; range, 60 to 97 years) with trochanteric region fractures applied with closed reduction and PFN with the same implant type, 21 who underwent surgery on a TT (TT group), and 21 on a RT (RT group). The cumulative radiation dose was the primary outcome and was measured as the dose area product (DAP) in Gray cm2 (Gycm2 ). Intraoperative fluoroscopy times and amount of radiation exposure were compared between the two groups. RESULTS: There was no significant difference between the two groups in terms of sex, age, body mass index, fracture side, and the AO Foundation/Orthopaedic Trauma Association (AO/OTA) fracture classification (p>0.05). No statistically significant difference was found between the TT and RT groups in terms of the mean intraoperative fluoroscopy time (48.29±22.31 and 55.95±21.54 sec, respectively; p=0.264) and amount of radiation exposure (2.26±1.86 and 2.84±1.96 Gycm2 , respectively; p=0.332). CONCLUSION: Both TT and RT with the patient positioned supine provide similar results for closed reduction and PFN of trochanteric region fractures, in terms of DAP as the most reliable measurement method. The main clinical relevance of this study is that radiation exposure of the patient need not be considered while selecting the operating table.

Delayed presentation of gluteal compartment syndrome presenting with peroneal palsy secondary to superior gluteal artery pseudoaneurysm following ballistic injury.

Gluteal compartment syndrome (CS) secondary to the superior gluteal artery (SGA) injury and pseudoaneurysm formation is a very rare condition. When it does occur, it usually manifests with acute and life-threatening hemorrhage resulting in early hypov-olemic changes. Delayed presentation of the gluteal CS (GCS) after trauma has been described in the literature seldom and these cases were demonstrated with sciatic nerve palsy, hemodynamic instability, decreased hemoglobin levels, increasing buttock pain, and a large gluteal hematoma. In this report, we present a case of GCS presenting with the palsy of the peroneal division of the sciatic nerve secondary to SGA pseudoaneurysm following ballistic injury, with a delay of nearly 20 days in diagnosis and treatment with normal hemodynamic findings. The patient required emergent angiographic embolization and then fasciotomy which were approx-imately 13 days after the onset of the symptoms. The patient made a positive recovery with no further neurologic deterioration and none local wound or systemic complications. This case emphasizes the importance of early diagnosis and treatment of this rare condition.

Battle Against Musculoskeletal Tumors: Descriptive Data of Military Hospital Experience.

Background: Management of musculoskeletal tumors remains challenging for orthopedic surgeons. The aim of this cross-sectional study was to present the prevalence and localization of musculoskeletal disorders diagnosed and treated at a tertiary referral military hospital. Method: A total of 552 patients' medical records who presented to our clinic between 2009 and 2014 with the diagnosis of musculoskeletal tumors were retrospectively analyzed according to age, gender, bone/soft tissue localization, histopathological diagnosis, incidence, and treatment. Results: Of the cases diagnosed with tumor, 225 were soft tissue localized, 317 bone localized, and 10 tumor-like lesions. The most common primary benign soft tissue tumors were lipoma, ganglion, and giant cell tumor of tendon sheath, while the most common malignant soft tissue tumors were liposarcoma and synovial sarcoma, respectively. The most common primary bone tumors were osteochondroma, enchondroma, and simple bone cyst, while the most common malignant bone tumors were osteosarcoma, Ewing sarcoma and chondrosarcoma, respectively. Myositis ossificans was found as the most common tumor-like lesion. Conclusion: Descriptive data in musculoskeletal tumors is crucial in terms of improving treatment and reducing mortality. In this study, no significant difference was found between the data of tertiary military hospital regarding epidemiology of musculoskeletal system tumors and those from the literatures around Turkey.

A Pilot Study of a Novel Fixation Technique for Fixation of Comminuted Patellar Fractures: Arthroscopic-Controlled Reduction and Circular External Fixation.

Patella fractures represent for 0.5 to 1.5% of all bony injuries in adults. Open reduction and the modified tension-band technique is the most common surgical technique used for patellar fractures. The purpose of this study is to present the outcomes of 26 comminuted patellar fractures treated with circular external fixator (CEF) under arthroscopic control and discuss its potential advantages over conventional surgical methods. This retrospective study included 26 patients who had closed comminuted patellar fractures and treated by CEF under arthroscopic control between January 2002 and March 2016. All patients treated with this technique were involved to the study as a consecutive series. Patients with noncomminuted transverse fractures were excluded, because they were treated with a different technique. Of the 26 patients 22 were male, 4 were female with the mean age of 33.5 years (range, 16-56 years). Patients were followed for 20 to 28 months (mean, 22 months). The mean time to union and the duration of fixation with the CEF ring was 12 weeks (range, 6-15 weeks). The mean Lysholm's score was 45 (range, 35-58) at the 10th postoperative day, which increased to 51 (range, 40-68) at the end of the first postoperative month and increased to 95 (range, 90-100) 1 month after CEF ring removal. Minor pin tract infection by pin-skin irritation was observed in nine patients. In one patient, refracture occurred due to a fall 19 days after CEF removal. CEF appears to be a safe and effective treatment for comminuted patellar fractures with a high union rate and minimal complications. It is safe and effective, as it allows short hospital stay and avoids a second surgery for removal of the instrument. Early rehabilitation with full weight-bearing promotes rapid recovery and quick return to work. Patients do not have a large unaesthetic scar on the anterior of the knee.

Direct Anterior Approach Versus Posterolateral Approach for Hemiarthroplasty in the Treatment of Displaced Femoral Neck Fractures in Geriatric Patients.

BACKGROUND In the present study, we aimed to evaluate early clinical and biochemical outcomes of direct anterior approach (DAA) versus posterolateral approach (PLA) for hemiarthroplasty in the treatment of displaced femoral neck fractures in geriatric patients. MATERIAL AND METHODS Between September 2012 and September 2017, a total of 110 patients who underwent hemiarthroplasty for displaced femoral neck fractures were retrospectively analyzed. The patients were divided into 2 groups according to the surgical technique PLA (Group 1, n=54) and DAA (Group 2, n=56). Clinical and biochemical results were compared. RESULTS There was no significant difference in the demographic characteristics of the patients, fixation type, and follow-up (P>0.05). However, there was a significant difference in the duration of surgery, amount of blood transfusion, change from baseline in postoperative hemoglobin levels, amount of intraoperative gauze dressing, amount of drainage fluid from the surgical wound, postoperative VAS scores, incision length, length of hospital stay, and Barthel Index scores in favor of DAA group (P<0.05). There was no significant difference in the degree of mobilization (P>0.05). None of the patients had postoperative complications in Group 1, while 3 patients in Group 2 developed a lateral femoral cutaneous nerve lesion and one patient had a missed iatrogenic fracture of the greater trochanter. CONCLUSIONS Our study results suggest that early clinical and biochemical outcomes are better in DAA than PLA with early return to daily living activities in patients undergoing hemiarthroplasty for displaced femoral neck fractures.

An anatomical examination of iatrogenic nerve injury during inside out meniscus repair with flexion and extension of the knee.

BACKGROUND: In this study, we aim to assess the safe, risky and high-risky zones by measuring the proximity of the needles to the peroneal and saphenous nerves in millimeters for the repair of tears of the anterior, middle and posterior horns of the medial and lateral menisci at flexion and extension position during inside-out repair technique. METHODS: First, a cadaveric study was conducted on 10 cadaver knees in which both (lateral and medial) menisci were divided into anterior, corpus and posterior with the longitudinal tear simulating in each section. The next phase involved the suture of the simulated tears of the menisci while the knee was at 90° of flexion and full extension. Finally, the distance from the exit points of the K-wire being inserted through meniscal anterior, corpus and posterior tears to the aforementioned nerves was measured with a digital caliper. RESULTS: The distance between K-wire exit points and neurovascular structures concerning corpus and anterior horn tear repair of both menisci were considered far away and not included. However, closer posterior menisci measurements were taken to avoid the risk of iatrogenic nerve injury. The measured distances for lateral meniscus posterior tears were recorded 11±5.2 mm at 90° of flexion and 8±4.5 mm at extension, whereas those recorded 17.3±5.7 mm at 90° of flexion and 13.7±4.7 mm at extension for medial meniscus. These variables were evaluated statistically using a paired t-test; the mean of t value was not considered statistically significant. CONCLUSION: Our results show that the inside-out technique at knee flexion is safe even in the posterior meniscus tears. However, safety distance can be increased with the higher flexion degrees of the knee. Lastly, in posterior meniscal tear repair, we recommend either retractor assisted mini-open technique at knee flexion, or all-inside suture technique, to avoid nerve injury risk in this zone. Although many surgeons do not prefer inside-out techniques for posterior menisci tears, inside-out posterior meniscal repair of both menisci is as safe as an all-inside technique using retractor assisted mini-open technique with the knee at higher than 90° flexion.

Mid-term Clinical and Radiological Results of Oxford Phase 3 Medial Unicompartmental Knee Arthroplasty.

Introduction The popularity of unicompartmental knee arthroplasty (UKA) for the treatment of isolated compartment osteoarthritis of the knee has risen over the past two decades. Currently, UKA covers a considerable amount of all knee arthroplasties worldwide. The aim of this study was to present the clinical and radiological outcomes of UKA in patients with medial compartment osteoarthritis. Methods Between January 2010 and January 2014, mobile-bearing UKA was applied to 44 knees of 37 (three men, 34 women) patients with isolated medial compartment osteoarthritis. The mean age, body mass index (BMI), and follow-up were 54 ± 6.1, 26.3± 2.2, and 48 ± 9.4, respectively. Oxford Knee Score (OKS), Knee Society Score (KSS), visual analog scale (VAS), and range of motion (ROM) were used for clinical assessment, and the Oxford Radiological Evaluation Criteria were used for radiological assessment. Results Compared to preoperative values, knee flexion increased from 116° to 123° (p<0.001). Statistically significant increases in OKS and KSS and decrease in VAS was obtained postoperatively (p<0.001). All of the components were aligned within the acceptable ranges radiologically. One bearing dislocation was revised and one conversion to TKA was performed during the 5.9-year follow-up. No major complications occurred, including infection, deep vein thrombosis, pulmonary emboli, and neurovascular injury. Conclusion The mid-term clinical and radiological outcomes of UKA were excellent in this study, and our results demonstrate that Oxford mobile-bearing UKA for the proper indication is effective, with considerable success in the treatment of medial compartmental knee osteoarthritis, regardless of age.

Safe and Effective Treatment Choice for Osteoid Osteoma: Computed Tomography-guided Percutaneous Radiofrequency Ablation.

Introduction Osteoid osteoma (OO) is a painful, benign, bone-forming tumor characterized by a small central nidus surrounded by sclerotic tissue. The aim of the present study was to evaluate the clinical outcome after computed tomography (CT)-guided radiofrequency ablation (RFA) in patients with OO performed from January 2012 to June 2018 and to confirm the safety and efficacy of CT-guided RFA. Methods Between January 2012 and June 2018, a total of 63 patients were treated with CT-guided RFA. Pre- and post-treatment pain, further treatment after the RFA procedure, observed complications, and satisfaction with the treatment were recorded for an assessment of clinical effects in all patients. The patients were evaluated with the visual analog scale (VAS) pre-procedure and at three months post-procedure. Results Of the patients, 39 were males and 24 were females with a mean age of 21 ± 9.7 (range, 9 to 41) years. The mean follow-up was 16 ± 2.1 (range, 12 to 19) months. The mean duration of the procedure was 34 ± 11.4 (range, 22 to 47) min. All of the patients were diagnosed with OO pathologically. A statistically significant difference was found between the pre-procedural and post-procedural VAS scores (p<0.001). Complications were observed in six patients including one peroneal nerve lesion, three minor skin burns, and two minor skin infections. Conclusion This study shows that CT-guided RFA is a safe and effective treatment for OO. It is thought that RFA could be the primary treatment choice for most OO with typical symptoms and radiological findings.

Brachial plexus injury: An unusual devastating complication during hospitalization in intensive care unit.

Brachial plexus injury due to prolonged immobilization of the arms in a hyper-abducted position during intensive care unit (ICU) follow-up is uncommon. In this article, we present an unusual case of a 20-year-old male drug addict who sustained unattended brachial plexus injury in left upper extremity after being bound over the axilla tightly during ICU follow-up. He had progressive numbness and near-total immobility of the left upper extremity. Atrophy, loss of muscle strength, and absence of deep tendon reflexes were observed in left upper extremity. Electrodiagnostic studies showed lower trunk partial axonal involvement. After aggressive physical therapy, patient's muscle function improved, showing full strength in all muscles innervated by median, ulnar, musculocutaneous, axillary and radial nerves. During follow-up of unconscious patients in ICU, clinicians and other staff should be more careful about restraining such patients by considering complications such as nerve injuries.

Total hip arthroplasty with rectangular stems and subtrochanteric transverse shortening osteotomy in Crowe type IV hips: a retrospective study.

BACKGROUND: The complexity of femoral and acetabular anatomy and restoring anatomic center of hip rotation in Crowe type IV developmental dysplasia of the hip (DDH) complicates standard reconstruction. The aim of this study is to evaluate surgical techniques and clinical outcomes of subtrochanteric transverse shortening osteotomy with the use of cementless rectangular cross-section femoral implants in Crowe IV dysplastic hips. METHODS: A total of 26 hips of 25 consecutive patients with Crowe type IV DDH who underwent cementless total hip arthroplasty with subtrochanteric femoral transverse shortening osteotomy were retrospectively analyzed. The Harris Hip Score, Visual Analog Scale-pain, leg length discrepancy, and vertical and lateral migration of hip rotation center were recorded. RESULTS: Mean age, follow-up, and time of union were 41 ± 9.7 years, 7.1 ± 1.2 years, and 3.7 ± 1.1 months, respectively. Mean Harris Hip Score significantly improved from 38 ± 5.7 to 86 ± 6.1 points postoperatively (P < .01). Mean leg length discrepancy and Visual Analog Scale significantly decreased from 4.3 ± 1.3 to 1.2 ± 0.6 cm, and 6.4 ± 1.2 to 1.8 ± 0.8 points, respectively (P < .01). One female patient had a dislocation due to acetabular liner wear, which was managed by liner and head change. One patient had Sudeck's atrophy, while another had pain on the lateral thigh, both of which were resolved with conservative management. CONCLUSIONS: Combined transverse subtrochanteric femoral osteotomy and cementless total hip arthroplasty with rectangular cross-section femoral implants is technically demanding, effective, and safe in femoral shortening for treatment of Crowe type IV DDH.

Imaging of Pelvic and Femoral Fixation Hardware: Normal Findings and Hardware Failure.

Good outcomes following treatment of pelvic ring injuries, acetabular fractures, and femur fractures rely on restoration of native pelvic or limb alignment, anatomical reduction and rigid stability of articular fractures, and early postoperative mobilization. Multiple surgical approaches, reduction aids, and orthopaedic implants are available to stabilize these fractures. Despite best practices, complications including hardware failure, nonunions, malunions, and infections occur. This article discusses common fracture classification systems, implants, and imaging findings associated with unwanted complications in fractures of the pelvis, acetabulum, and femur.

Is staged management with immediate conversion of external fixation to retrograde intramedullary nailing for combat-related Gustilo Type III supracondylar femur fractures safe and reliable method?

INTRODUCTION: Femur fractures due to bomb explosions and gunshots in battlefield require osseous stabilization as quickly as possible to expedite emergent conditions. Immediate external fixation is the initial procedure as usual with planned early conversion to definitive treatment. The purpose of the current study is to determine the results of the early retrograde intramedullary nailing in combat-related injuries. MATERIAL AND METHODS: Eighteen patients with comminuted supracondylar femur fractures, initially treated with external fixation followed by planned conversion to retrograde intramedullary nailing in a one-stage procedure, were evaluated in a retrospective review to gather demographic, injury, management, and fracture-healing data for analysis. RESULTS: According to the system of Gustilo Anderson and Orthopedic Trauma Association, all fractures were open type III and 33-A3, respectively. The mean follow-up, operation time and union time were 1.8 years (range, 6 months to 2,6 years), 75 min (range, 60-100), and 3 months (range, 1.5-4), respectively. There was one complication of acute osteomyelitis which was successfully treated with antibiotic-load beams and aggressive bone debridement. No septic arthritis was observed. CONCLUSIONS: We concluded that immediate retrograde intramedullary nailing in combat-related supracondylar femur fractures regardless of contamination even in Gustilo type III is a safe and reliable treatment method.

Treatment of implant-related methicillin-resistant Staphylococcus aureus osteomyelitis with vancomycin-loaded VK100 silicone cement: An experimental study in rats.

INTRODUCTION: The purpose of this present study is to investigate the efficacy of vancomycin-loaded VK100 silicone cement drug delivery system in the treatment of implant-related methicillin-resistant Staphylococcus aureus (MRSA) osteomyelitis in rats. MATERIALS AND METHODS: Thirty-six adult (18-20 weeks old) female Sprague-Dawley rats were included in the study. All rats underwent experimental osteomyelitis surgery via injecting 100 µL bacterial suspension of MRSA into the medullary canal. After a 2-week duration for the formation of osteomyelitis model, rats were assigned randomly into four groups: control (C), systemic vancomycin (V), local vancomycin-loaded VK100 silicone cement (vVK100), and systemic vancomycin and local vancomycin-loaded VK100 silicone cement (V+vVK100). The following treatment protocols were administered to each group for 4 weeks. For group C, 0.9% saline solution equivalent to the volume of vancomycin dose (approximately 1 ml/kg) was administered intraperitoneally twice daily (12-h intervals). For group V, 15 mg/kg of vancomycin was administered intraperitoneally twice daily (12-h intervals). For group vVK100, vVK100 polymer was included so that the intramedullary canal of the rats are affected. For group V+vVK100, vVK100 polymer was included so that the intramedullary canal of the rats are affected and 15 mg/kg of vancomycin was administered intraperitoneally twice daily (12-h intervals). After 4 weeks of treatment, clinical, radiologic, microbiologic, and histopathologic evaluations were performed for all groups. RESULTS: Results of this study revealed that all scores of the evaluation criteria for the treatment groups (groups V, vVK100, and V+vVK100) decreased due to the treatment protocols when compared to group C. These results show the effectiveness of all treatment protocols for the implant-related chronic MRSA osteomyelitis. However, there were no statistical difference between these three protocols. CONCLUSIONS: vVK100 polymer, as a local antibiotic delivery system, seems to be an effective method for the treatment of implant-related chronic MRSA osteomyelitis.

Intramedullary elastic nailing of the displaced radial neck fractures in children.

OBJECTIVE: The aim of this study was to report the clinical and radiological results of 11 patients with Judet type 3 severely displaced radial neck fractures, who were treated with intramedullary elastic nail fixation with the help of percutaneous K-wire reduction maneuver (Métaizeau technique). METHODS: A total of 11 children (4 boys and 7 girls with a mean age of 7.7 (6-10) years) with Judet type 3 radial neck fractures were treated in our clinic between February 2013 and August 2015. The fractures were evaluated according to Judet classification system modified by Métaizeau. Reduction and fixation was performed within the first 24 h after injury in all patients. All fractures were treated by closed reduction using distal elastic intramedullary nail. Clinical evaluation was performed by measuring elbow range of motion (ROM) with goniometer, radiological evaluation by assessing fracture healing and functional evaluation by using Mayo Elbow Performance Score (MEPS). RESULTS: The mean MEPS score increased from 15 points preoperatively to 88 points postoperatively (range, 12-95 points). Radiological evaluation revealed that all fractures healed with excellent or good alignment. The mean flexion was 150° (range, 145-154°), extension 1° (range, 0-2°), supination 82° (range, 80-86°), and pronation 83° (range, 80-85°). CONCLUSION: Reduction and osteosynthesis of radial neck fractures by intramedullary nailing with the help of percutaneous K-wire manipulation appears to be a simple, safe and effective treatment method in children. LEVEL OF EVIDENCE: Level IV, Therapeutic study.