Unveiling Syndesmotic Malreduction: A Proof-of-Concept towards Portable Ultrasound Detection.

Objectives: To evaluate the utility and diagnostic performance of portable handheld ultrasound for evaluating fibular rotation at the distal tibiofibular articulation after syndesmotic disruption. Methods: Four above-the-knee cadaveric specimens were included. Syndesmotic disruption was precipitated by transecting the Anterior Inferior Tibiofibular Ligament, Interosseous Ligament, and Posterior Inferior Tibiofibular Ligament. Thereafter, a proximal fibular osteotomy was performed, and three conditions were modeled at the distal syndesmosis: 1) reduced, 2) 5 degree internal rotation malreduction, and 3) 5 degree external rotation malreduction. Two blinded observers performed separate ultrasonographic examinations for each condition at the level of both the anterior and posterior distal tibiofibular articular surfaces. Syndesmotic gap penetrance, defined as the ability of the P-US to generate signal between the distal fibula and tibia at the level of the incisura, was graded positive if the sonographic waves penetrated between the distal tibiofibular joint and negative if no penetrating waves were detected. The accuracy measures of the anterior and posterior gap penetrance were evaluated individually. Results: Our preliminary results showed that posterior gap penetrance showed good performance when detecting either internal or external rotational malreduction of the fibula with very good specificity (87.5%) and PPV (90.0%). On the other hand, the anterior gap penetrance showed limited performance when detecting either form of rotational malreduction. Conclusion: We introduced a novel sign, the "gap penetrance sign", best measured from the posterior ankle, which can accurately detect syndesmotic malreduction using P-US in a manner that does not require specific quantitative measurements and is readily accessible to early P-US users.

Midterm treatment results of congenital dislocation of the knee in 14 knees of nine cases.

Patients with congenital dislocation of the knee (CDK) should be promptly treated surgically if conservative measures fail. This study aimed to achieve a better understanding of the diagnosis and management of CDK through sharing our experience and contributing to the existing literature. Nine patients with a total of 14 knees were included in the study. All patients except one were initially treated with gentle manipulation and serial casting. Surgery was performed on patients in whom sufficient joint mobility could not be achieved. Active and passive range of motion of the knees and functional outcome were measured. Of the 14 knees, five were classified as first grade, four as second grade and five as third grade. The mean age of the patients was 4.09 months and the follow-up period was 70 months. The initial mean flexion angle (MFA) was 18.2° (0-90) and the mean extension angle (MEA) was 8.2° (0-15). At the final follow-up, the mean MFA was 109.2° (80-140) and MEA was -2.85° (0 to -10). No patient had instability by the final follow-up. The results were classified as excellent (5 knees), good (5 knees) and moderate (4 knees) according to outcome assessment criteria. The functional outcomes were classified as excellent (7 knees), good (3 knees) and fair (4 knees) according to the functional outcome scoring. Treatment of CDK should be started in the first days of life, and if the desired functional outcome cannot be achieved through conservative treatment, surgical treatment should be planned without delay.

In silico comparative biomechanical analysis of oblique and chevron medial displacement calcaneal osteotomies for pes planus deformity.

BACKGROUND: Medializing displacement calcaneal osteotomy is commonly performed as part of reconstructive surgery for patients with valgus hindfoot and progressive pes planus deformity. Among several types of calcaneal osteotomies, the oblique and Chevron osteotomy patterns have been commonly described in the literature and gained popularity as they are easily reproducible through percutaneous techniques. Currently, there is scarce evidence in the literature on which cut pattern is superior in terms of stability. To investigate the impact of cut pattern and posterior fragment medialization level on foot biomechanics, computational methods are employed. METHODS: Ankle weightbearing computer tomography (CT) scans of seven patients diagnosed with stage II pes planus deformity are segmented and converted into 3D computational models. Oblique and Chevron osteotomy patterns are modeled independently for each patient. The posterior fragments are medially translated by 8-, 10- and 12-mm and subsequently fixated to the anterior calcaneus with two screws. A total of 42 models are exported to finite element software for biomechanical simulations. Among the investigated parameters, the higher stiffness and lower von Mises stress at the osteotomy interface and the screw site are assumed to be precursors of better stability. RESULTS: It is recorded that as the medialization level increases, the stiffness decreases, and overall stresses increase. Also, it is observed that the Chevron cut produces a stiffer construct while the overall stresses are lower, indicating better stability when compared to the oblique cut. The statistical comparisons of the relevant groups that support these trends are found to be significant (p < 0.05). CONCLUSION: Chevron osteotomy showed superior stability compared to the oblique osteotomy while underscoring the negative impact of increased medialization of the posterior fragment. CLINICAL RELEVANCE: Opting for a lower medialization level and implementing the Chevron technique may facilitate union and earlier weightbearing.

Effect of sequential burr passes on minimally invasive akin and first metatarsal dorsiflexion osteotomies.

BACKGROUND: Minimally invasive surgical (MIS) osteotomies are increasing as a surgical option for treating midfoot and forefoot conditions. This study aimed to evaluate the impact of each burr pass on the degree of correction, gap size, and alignment in MIS Akin and first metatarsal dorsiflexion osteotomies (DFO). METHODS: MIS Akin and first metatarsal DFO were performed on ten cadaveric specimens. Fluoroscopic measurements included the metatarsal dorsiflexion angle (MDA), dorsal cortical length (MDCL), first phalangeal medial cortical length (PCML) and proximal to distal phalangeal articular angle (PDPAA). RESULTS: The average decrease in PCML with each burr pass was as follows: 1.53, 1.33, 1.27, 1.23 and 1.13 mm at the 1st to 5th pass, respectively. The MDCL sequentially decreased by 1.80, 1.59, 1.35, 0.75, and 0.60 mm. The MDA consistently decreased, and the PDPAA incrementally became more valgus oriented. CONCLUSION: On average, a first metatarsal dorsal wedge resection of 4.7 mm and first phalangeal medial wedge resection of 2.9 mm was achieved after 3 and 2 burr passes, respectively. This data may aid surgeons determine the optimal number of burr passes required to achieve the desired patient-specific surgical correction.

Effect of sequential burr passes on osteotomy magnitude and calcaneal morphology in minimally invasive Zadek osteotomy.

PURPOSE: This study aimed to evaluate the impact of each burr pass on degree of correction, gap size and calcaneal morphology in MIS Zadek osteotomy. METHODS: MIS Zadek osteotomy was performed on ten cadaveric specimens using a 3.1 mm Shannon burr. After each burr pass, the osteotomy gap was manually closed, and the subsequent burr passes were carried out with the foot held in dorsiflexion, which was repeated five times. Lateral X-rays were taken before and after each burr pass. Two independent reviewers measured the dorsal calcaneal length after each burr passage, as well as changes in several calcaneal parameters including X/Y ratio, Fowler Philip angle, and Böhler angle. RESULTS: The average decrease in dorsal calcaneal cortical length with each burr pass was as follows: 2.6 ± 0.9 mm at the 1st pass, 2.4 ± 1 mm at the 2nd pass, 2 ± 1 mm at the 3rd pass, 1.6 ± 1 mm at the 4th pass, and 1.4 ± 0.7 mm at the 5th pass. The Fowler Philip and Böhler angles consistently decreased while the X/Y ratio consistently increased following each consecutive burr pass. Interobserver reliability analysis demonstrated good agreement for all parameters. CONCLUSION: The results revealed the trends of length and anatomical changes in the calcaneus with each burr pass. On average, a dorsal wedge resection of 10 mm was achieved after 5 burr passes. This data can aid surgeons in determining the optimal number of burr passes required for a particular amount of resection, ensuring the attainment of the desired patient-specific surgical outcome.

Comparison between achilles tendon reinsertion and dorsal closing wedge calcaneal osteotomy for the treatment of insertional achilles tendinopathy: A meta-analysis.

BACKGROUND: The debridement and Achilles tendon reinsertion (DATR) have been the most common surgical approach for the treatment of Insertional Achilles Tendinopathy (IAT), while dorsal closing wedge calcaneal osteotomy (DCWCO) has recently gained popularity as an alternative surgical option. This study aimed to systematically review the published literature on both surgical techniques and compare their clinical outcomes and complication rates. METHODS: A systematic review was performed according to the PRISMA guidelines using Medline, Embase, and Scopus databases. The inclusion criteria encompassed clinical studies reporting functional outcomes and complications, with a minimum of 10 patients and at least 12 months of follow-up. RESULTS: Seven studies (n = 169) were included for the analysis of DATR, and eight studies (n = 227) were included for the analysis of open DCWCO. Both groups showed a similar improvement in AOFAS score. The overall complication rates were 16.6% in the DATR group and 9.2% in the DCWCO group, but the difference was not statistically significant. However, there was a significantly higher incidence of wound complications in the DATR group (10.1%, 95% C.I.: 4.7-15.6) compared to the DCWCO group (2.5%, 95% C.I.: 0.6-4.4) as the confidence intervals did not overlap. CONCLUSIONS: Clinical outcomes and overall complication rates of both techniques were comparable, although DCWCO had a lower incidence of wound complications. Further research should be focused on prospective studies comparing the two techniques to corroborate the current findings. LEVEL OF EVIDENCE: Level IV; meta-analysis.

Are acromiohumeral distance measurements on conventional radiographs reliable? A prospective study of inter-method agreement with ultrasonography, and assessment of observer variability.

OBJECTIVES: This study aims to investigate the reliability of acromiohumeral distance (AHD) measurements using conventional radiographs and to compare non-standardized and standardized radiographs with intra-/interobserver reliability measurements. PATIENTS AND METHODS: Between February 2021 and January 2022, a total of 110 shoulders of 55 patients (25 males, 30 females; mean age: 49.7±12.6 years; range, 25 to 77 years) were included. Radiographs were taken in four different positions: primarily shoulder anteroposterior (AP), true AP, standardized true AP, and standardized outlet views. The AHD was measured by three orthopedists. A prospective ultrasonography (US) evaluation was performed by an experienced physiatrist, and the relationship between US and radiographic measurements was evaluated. The intra- and interobserver reliability of radiographic measurements was assessed. RESULTS: On the standardized true AP view measurements, all observers showed a moderate to good agreement with US measurements (intraclass correlation coefficients [ICC]: 0.68-0.75). There was no significant difference between the AHD measurements of the senior orthopedist on standardized true AP and outlet views, and the US measurements. The intraobserver agreement of US measurements was excellent (ICC: 0.98, 95% confidence interval [CI]: 0.98-0.99), and the intraobserver agreement level of measurements on radiographs were good to excellent with a wide range of ICC values (ICC: 0.79-0.97). Interobserver reliability was the highest on the standardized outlet view, with an ICC of 0.91 and 0.88 in two measurement times. Interobserver reliability of other measurements were good with ICC values ranging from 0.82 to 0.88. CONCLUSION: The AHD measurements on radiographs are compatible with US measurements within up to 2 mm difference if standardization is ensured. Also, measurements on standardized views have a superior consistency with lower standard error of measurement and minimal detectable change values. Therefore, we recommend using standardized true shoulder AP and standardized outlet radiographs in clinical practice and studies, as these are the most accurate in demonstrating true AHD.

The uselessness of using salivary microbiota in forensic identification purposes of a person with recent antibiotic use.

The detection of microbial flora changes in saliva samples because of antibiotic use through advanced molecular genetic analysis is important for forensic and clinical applications. This study aims to reveal the variability in the microbial structure of human saliva after antibiotic use with metagenomic analysis techniques from a forensic point of view. Within the scope of the study, saliva samples were collected from patients who were under the effect of regional anesthesia to be administered a standardized course of antibiotic therapy that lasted for a week. The analysis was conducted on 56 saliva samples from 14 individuals over four different time intervals. Isolation of the 16S rRNA region and PCR analysis were performed prior to sequence analysis to determine the microbiome structure of the samples at phylum, genus, and species levels. As expected, changes were observed in bacterial species found in saliva samples after administration of antibiotics and this was linked to the specific type of antibiotics that were administered. This change was statistically significant for Firmicutes, Spirochetes, and Verrucomicrobiota. Furthermore, although the oral microbiome tends to return to its former state at the phylum and genus level within a 4-week period after the start of antibiotic use, it is observed that the change, especially in some bacterial species, still continues. The findings of this study show that because of the inability of stabilization at species-level in a period of 4 weeks from the start of antibiotic use, it is not suitable to assess saliva samples at species-level for forensic identification.

Exploration of Flexible Pes Planus as a Potential Risk Factor for Cardiac Pathologies in Pediatric Cases.

OBJECTIVE: The aim of this study is to investigate the relationship between flexible pes planus (FPP) and cardiac pathologies in pediatric patients, with a particular emphasis on hypermobility status. METHODS: Between January and June 2022, a retrospective screening was conducted on a total of 68 patients aged between 6 and 18 years who had been diagnosed with FPP. Eight patients were excluded from the study due to suspicion of connective tissue or neuromuscular diseases following systemic examinations conducted by a pediatric specialist. The included 60 patients underwent comprehensive cardiac examinations conducted by pediatric cardiology specialists and were evaluated through echocardiography (ECHO) as part of the study. Simultaneously, a control group of healthy individuals aged 6 to 18, without a diagnosis of pes planus (PP), was selected from those who applied for health reports for the purpose of obtaining sports licenses. Patients diagnosed with FPP were compared to a control group in terms of the presence of cardiac pathology. Furthermore, the Beighton Hypermobility Scores (BHSs) of patients diagnosed with FPP were compared based on the presence of cardiac pathology. RESULTS: A total of 60 patients (40 males, 20 females) diagnosed with FPP were included in the study, and a control group consisting of 453 healthy individuals (287 males, 166 females) was selected. The incidence of cardiac pathology in patients diagnosed with FPP (23.3%) was found to be significantly higher compared to the control group (7%) (p <0.01). The risk of cardiac pathology in patients diagnosed with FPP was determined to be four times higher compared to the control group (Odds ratio: 4 (1.993-8.046), p<0.01). Among patients with FPP, individuals who were found to have cardiac pathology had statistically significantly higher average BHSs compared to those without cardiac pathology (p: 0.043). CONCLUSIONS: Our study suggested that there may be a significant relationship between FPP and high cardiac pathology risk in pediatric patients. We observed a significant increase in the incidence of cardiac pathologies among patients diagnosed with FPP. Additionally, the presence of higher hypermobility scores among patients diagnosed with FPP suggests a potential connection between the two. In the evaluation of FPP in the pediatric population, it should be considered as a potential risk factor for cardiac pathologies and its potential association with hypermobility.

Characteristics and Research Trends of the 100 Most-Cited Flatfoot Articles.

BACKGROUND: Bibliometric studies in the field of orthopedics have increased because of the large volume of the available literature that prevents understanding the general status of the related field. This study aimed to identify and analyze the 100 most-cited articles related to flatfoot to reveal their characteristics and research trends. METHODS: Available literature on the Web of Science database until the end of 2020 were analyzed, and the 100 most-cited articles were determined. The characteristics of articles including publication year, authors, institutions, country, journal, number of pages, number of references, study design, level of evidence, main topic, age group, the specialty of the first author, and availability of funding were extracted and statistically analyzed for any association with the number of citations or citation density. RESULTS: The average citation number was 63.1 ± 43.8 (range, 30-278). The average citation density was 3.4 ± 1.8 (range, 0.8-12.6). The United States was the leading country with 65 articles, followed by Taiwan and the United Kingdom with five articles from each. Twenty-six papers had Level III evidence and 36 papers had Level IV evidence. Only three studies had Level I evidence and three had Level II evidence. The majority of articles (43 papers) were published in Foot & Ankle International. Citation density was positively correlated with publication year (P < .001) and the number of references (P = .004). CONCLUSIONS: The available data provide general characteristics of the 100 most influential papers about flatfoot. The vast majority of papers had a low level of evidence, indicating the need for higher quality research.

Investigation of lattice infill parameters for additively manufactured bone fracture plates to reduce stress shielding.

BACKGROUND: Stress shielding is a detrimental phenomenon caused by the stiffness mismatch between metallic bone plates and bone tissue, which can hamper fracture healing. Additively manufactured plates can decrease plate stiffness and alleviate the stress shielding effect. METHODS: Rectilinear lattice plates with varying cell sizes, wall thicknesses, and orientations are computationally generated. Finite element analysis is used to calculate the four-point bending stiffness and strength of the plates. The mechanical behaviors of three different lattice plates are also simulated under a simple diaphyseal fracture fixation scenario. RESULTS: The study shows that with different combinations of lattice infill parameters, plates with up to 68% decrease in stiffness compared to the 100% infill plate can be created. Moreover, in the fixation simulations, the least stiff lattice plate displays 53% more average stress distribution at the healing callus region compared to the 100% infill plate. CONCLUSIONS: Using computational techniques, it has been demonstrated that additively manufactured stiffness-reduced bone plates can successfully address stress shielding with the strategic modulation of lattice infill parameters. Lattice plates with design versatility have the potential for use in various fracture fixation scenarios.

Angle bisector method to determine the accurate angle for tibiofibular syndesmotic fixation: A validation study with 3D-printed anatomical models.

PURPOSE: This study aimed to validate the angle bisector method on 3D-printed ankle models to reveal whether it aids in placing syndesmotic screws at an accurate trajectory that is patient- and level-specific and also not surgeon-dependent. METHODS: DICOM data of 16 ankles were used to create 3D anatomical models. Then the models were printed in their original size and two trauma surgeons performed the syndesmotic fixations with the angle bisector method at 2 cm and 3.5 cm proximal to joint space. Afterward, the models were sectioned to reveal the trajectory of the screws. The photos of the axial sections were processed in a software to determine the centroidal axis which is defined as true syndesmotic axis and analyze its relationship with the screws inserted. The angle between the centroidal axis and syndesmotic screw was measured by two-blinded observers 2 times with 2 weeks interval. RESULTS: The average angle between the centroidal axis and screw trajectory was 2.4° ± 2° at 2 cm-level and 1.3° ± 1.5° at 3.5 cm-level, indicating a reliable direction with minimal differences at both levels. The average distance between fibular entry points of the centroidal axis and screw trajectory was less than 1 mm at both levels indicating that the angle bisector method can provide an excellent entry point from fibula for syndesmotic fixation. The inter- & intra-observer consistencies were excellent with all ICC values above 0.90. CONCLUSION: The angle bisector method provided an accurate syndesmotic axis for implant placement which is patient- & level-specific and not surgeon-dependent, in 3D-printed anatomical ankle models.

Cortices of Fibula and Tibia Can Provide Landmarks for Accurate Syndesmosis Fixation Angle: Computed Tomography Validation of Angle Bisector Method.

Anatomic syndesmosis reduction is necessary to restore ankle biomechanics and prevent poor clinical outcomes, but malreduction can be encountered frequently since the ideal fixation angle varies between patients and fixation levels. This study aimed to validate the angle bisector method to reveal whether it provides an accurate syndesmotic fixation angle that is patient- and level-specific. Lower extremity CT angiography of 50 consecutive patients (25 male, 25 female) without evident ankle pathology were evaluated. The average age was 52.8 (±18, range: 18-75). Lines tangent to anterior and posterior cortices of tibia and fibula were drawn in the axial plane at both 2 cm and 3.5 cm above the ankle joint line. Bisection of the angle formed between these lines was drawn and its relationship with the centroidal axis, which is proposed to be the ideal syndesmotic axis, was evaluated. The angle between the bisector line & the centroidal axis and the distance between their most lateral intersections with the fibula were calculated. The measurements were made by 3 blinded observers. Intra- and interobserver reliability analyses were conducted. The average centroidal axis-bisector angle was 2.1° ± 2.1° at 2 cm and 0.6° ± 1.3° at 3.5 cm level. The average distance to the actual syndesmosis entry point was 1.0 ± 0.9 mm at 2 cm and 0.4 ± 0.4 mm at 3.5 cm level. The values didn't show any significant difference according to gender. Intra- and interobserver reliability analysis showed excellent correlation in all parameters (interclass correlation coefficient > 0.90). Angle bisector method was found strongly reliable providing accurate direction for syndesmotic axis. It can provide a patient- and level-specific angle for the application of syndesmotic implants without increasing the fluoroscopy exposure. Its use can have a broad impact on functional outcomes of ankle injuries by decreasing the malreduction rates. Further cadaveric validation and safety studies should be conducted for possible clinical usage.

Middle-sized posterior malleolus fractures: Fixed versus non-fixed - A prospective randomized study.

PURPOSE: This study aimed to assess the impact of fixation on functional and radiological outcomes of ankle fractures involving the posterior malleolus. We hypothesized that fixation of the posterior malleolus would be associated with improved radiological and functional outcome. METHODS: A prospective randomized controlled study was planned and 40 consecutive ankle fractures involving middle-sized (10-25%) posterior fragment were included. Posterior fragments in Group 1 were not fixated while Group 2 underwent posterior malleolus fixation. The patients were evaluated both functionally and radiologically at minimum 2-years. RESULTS: Demographics and fracture type distributions were similar between the groups. Despite the slightly better functional outcome in Group 2, no significant functional or radiological outcome difference could be detected. Articular step-off> 1 mm was more common in Group 1 (p = 0.04) and the patients with articular step-off showed significantly worse functional outcome in all functional parameters (p < 0.05). Radiological and functional outcome parameters were positively correlated when all patients were evaluated together. Lateral radiographs caused an overestimation in the size of posterior fragment compared to CT (p < 0.001). CONCLUSION: Although there was a slightly better clinical outcome in patients with fixed posterior fragments, it was not significant at short to mid-term follow-up. However, posterior fragment fixation contributed to functional outcomes by decreasing the incidence of articular step-off> 1 mm, which was found to be a negative prognostic factor. LEVEL OF EVIDENCE: Level I; prospective randomized controlled study.

Diagnosis and Treatment Planning of Developmental Hip Dysplasia: Evaluation of Care Practices of the Members of the Turkish Pediatric Orthopedics Association.

OBJECTIVE: Developmental dysplasia of the hip is one of the most important causes of childhood disabilities. Although there are accepted treatment algorithms for developmental dysplasia of the hip, diagnosis and treatment approaches can show variations in the management among physicians. This study aimed to develop a diagnosis and treatment algorithm for developmental dysplasia of the hip according to the preferences of members of the Turkish Pediatric Orthopedics Association. MATERIALS AND METHODS: An interview by telephone call was made with 76 orthopedists (group 1: more experienced 39 physicians, group 2: less experienced 37 physicians) who are members of the Turkish Pediatric Orthopedics Association. Participants were q uesti onnai red ab out their demographic information, experiences, diagnostic criteria that they use for developmental dysplasia of the hip, and treatment approaches to patient scenarios of different ages. RESULTS: Most of the participants recommended universal screening at the age of 4 weeks. It was observed that the most significant physical examination finding was limited hip abduction, and the most frequently used radiographic evaluation on x-ray was acetabular index measurement. The most frequently used description for dysplasia was found as acetabular index >30°. CONCLUSIONS: Although there are some differences among orthopedists in the diagnosis, treatment, and follow-up approach of developmental dysplasia of the hip, there was no significant difference according to the experience-based grouping. The treatment algorithm, which was created with the most frequently given answers, was designed, which we think may be beneficial for pediatricians and orthopedists.

Maggot Treatment of Necrotic Toe Developed After Traumatic Subtotal Amputation.

Maggot debridement therapy (MDT) has been used for years in the treatment of chronic wounds and necrotic tissues. We report a case of subtotally amputated third toe that was treated with MDT after reattachment and developing complete necrosis. The necrotic toe was replaced with viable tissue and the wound healed completely after 2 weeks of MDT application. This case points out the regenerative effects of MDT besides its mechanical debridement effect on the necrotic tissue.

Treatment of Recalcitrant Isolated Congenital Fibular Pseudarthrosis: Fibular Segment Transfer and Tibiofibular Synostosis with Unilateral External Fixator.

Isolated congenital pseudarthrosis of the fibula is a rare entity with a limited number of cases reported in the literature. Treatment is challenging because of recalcitrant nonunion and because no consensus about the best treatment plan exists. We report a case of isolated congenital fibular pseudarthrosis with valgus deformity of the ankle. The patient had a history of two failed operations. We used a novel surgical plan that combined tibiofibular synostosis with fibular segment transfer through a unilateral external fixator. The patient showed good early results with fibular union. We advocate the combination of tibiofibular synostosis and fibular segment transfer to restore the integrity and stability of the ankle in recalcitrant isolated congenital fibular pseudarthrosis cases with a history of failed surgery.

Intralesional curettage and cementation of low-grade chondrosarcomas of the appendicular skeleton: Long-term results from a single center.

OBJECTIVE: The purpose of this study was to investigate the results and complications in patients who had low-grade chondrosarcomas in the appendicular skeleton and were treated by intralesional curettage and cementation within the scope of 25 years of experience in a single center. METHODS: Ninety-one patients (72 female and 19 male) were retrospectively analyzed. The median at the time of surgery was 43 (17-78) years, and the median follow-up was 102 (26-288) months. All patients were treated by intralesional curettage followed by cementation with high-viscosity bone cement (polymethylmethacrylate). Complications and local recurrence rates, as well as clinical outcome scores were recorded. RESULTS: Five patients (5.49%) developed local recurrence at an average of 6.6 (6-9) months postoperatively. Four were treated with local wide excision and reconstruction with tumor prosthesis. One patient received recurettage and cementation. Two recurred patients were dedifferentiated into grade II chondrosarcomas in the last intervention. No major postoperative complication was identified in the series. Patients achieved an average Musculoskeletal Tumor Society scoring system of 92.4% (standard deviation 5.2; range 80-100) in the sixth postoperative month. Musculoskeletal Tumor Society scores in the recurrent patients decreased from an average of 90% to 75.3% after the final intervention. CONCLUSION: Intralesional curettage and cementation seem safe and reliable techniques with low recurrence and complication rates in treating low-grade chondrosarcomas of the appendicular skeleton. Clinical, radiological, and pathological evaluations are mandatory before surgical intervention, and a multidisciplinary approach is crucial. A strict follow-up regimen in the early postoperative period is needed and strongly recommended to detect local recurrence. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Bibliometric analysis of 100 most influential papers related to septic arthritis of native joints.

Aim: Bibliometric studies have gained popularity since they are able to define the characteristics of articles on specific subjects. The aim of this study was to analyze the characteristics of 100 most-cited papers related to septic arthritis of the native joints. Methods: Web of Science database was analyzed and 100 most-cited articles about septic arthritis were determined. The characteristics of the articles including publication year, country, journal, study type, and sponsorship were recorded and investigated for any possible relationship with citation numbers. The visualization of the most commonly used keywords was made by software. Results: The highest citation number and density were 309 and 21.6, respectively. The highest contribution was from the USA with 44 articles. The most common study type was case series with 26 articles. Annals of the Rheumatic Diseases journal had the highest number of articles with 8 papers. Fifteen studies were funded. The average citation density of review articles was significantly higher than in clinical and basic science studies (p < 0.001). Citation density was positively correlated with publication year and institution number, while it was negatively correlated with the level of evidence. Conclusion: This study summarizes the general characteristics and research trends of the 100 most influential septic arthritis papers. Citation density and level of evidence performance were better in more recent articles. Additionally, citation density was higher in papers that included contributions from multiple institutions and papers with a high level of evidence. However, a high level of evidence is lacking indicating the need for better study design in future research.

The Effect of Preoperative Albendazole Treatment on Intramuscular Cyst Structure in a Patient with Simultaneous Cystic Echinococcusis of Liver and Vastus Lateralis Muscle.

We report a 44-years-old woman with cystic echinococcosis (CE) who presented with simultaneous involvement of liver and vastus lateralis muscle to Istanbul University-Cerrahpasa, Istanbul, Turkey in 2020. Although she underwent surgery for the liver, the intramuscular mass was ignored. While the patient was under post-operative albendazole treatment, she was investigated for the mass on her right thigh which was excised later. The comparison of magnetic resonance imaging before and after albendazole treatment showed that albendazole eliminated the intramuscular vesicle structures by accelerating the degeneration process of the cyst. The comparison of pathology samples sent from both liver and intramuscular CE also revealed that the albendazole has left the laminar membrane intact, degenerate the germinative membrane, thereby reducing the intra-vesicle pressure and also caused the scolex structures to disappear. To the best of our knowledge, this is the first paper to report the effect of preoperative albendazole treatment on the structure of intramuscular CE.