A Scoring System to Demonstrate the Risk for Bone Injury in Patients with Clinically Suspected or Occult Scaphoid Fracture.

BACKGROUND: It is important to diagnose a scaphoid fracture accurately and start the correct treatment in the shortest time possible. However, the fracture of bone may not be visible on x-ray. In such cases, patients are clinically diagnosed with suspected or occult scaphoid fractures. The aim of this study was to define a scoring system based on physical examination to demonstrate the risk for bone injury in patients with clinically suspected and occult scaphoid fractures with negative radiographs and anatomical snuff box tenderness and to decrease the costs and workforce loss due to unnecessary treatment and magnetic resonance imaging (MRI). MATERIALS AND METHODS: Patients were initially evaluated by the attendant orthopedic physician in the emergency service with X-ray of the wrist, and ten wrist physical examination techniques were used. The X-rays of patients were evaluated by three orthopedic surgeons. Finally sixty patients, who were diagnosed as having no fracture by all three orthopedic surgeon, were included in the study. The wrists of these patients were evaluated with MRI. RESULTS: There were 46 male (77%) and 14 female (23%) patients with a mean age of 21.5 years (range 7-61 years). About 3.3% had triquetrum fracture, 15% had bone edema in the scaphoid and radius, 18.3% had distal radius fracture, 31.6% had scaphoid fracture, and 31.8% had no bone injury. A scoring system was also proposed. It can be predicted that in the physical examination of the wrist if the total score is higher than 6.5, the probability of fracture is 2.87 (positive likelihood ratio) fold compared to scores below 6.5. CONCLUSIONS: Proposal of this new scoring system was thought to be useful for predicting the risk for bone injury in patients with clinically suspected scaphoid fractures and making decision regarding therapeutic options.

Influence of sagittal plane malpositioning of the patella on anterior knee pain after tibia intramedullary nailing.

PURPOSE: Anterior knee pain (AKP) is one of the most common complications after tibia intramedullary surgery. We evaluated changes in patellar tendon length after tibia intramedullary nailing surgery using a transtendinous approach and assessed the importance of nail position in relation to the anterior tibial cortex and joint line. METHODS: Two surgeons blinded to patients' pain status measured both the knee Insall-Salvati and Caton-Deschamps indexes on 30° flexion lateral knee X-rays of 33 patients. Superior nail prominence (the distance from the proximal tip of the nail to the tibial plateau) and anterior nail prominence (the distance from the anterior tip of the nail to the anterior tibial cortex) were measured on the CT. RESULTS: Clinical assessment showed that 10 patients (30 %) had AKP at the last follow-up. HSS and Lysholm scores and the incidence of AKP were similar between patients whose IM nails were removed and those who still had them. HSS score, Insall-Salvati, and Caton-Deschamps indexes were significantly lower in the operated extremity than in the healthy limb at last follow-up. No association was demonstrated between AKP and nail position in relation to the anterior tibial cortex or tibial plateau. CONCLUSIONS: According to our study, although the patellar tendon shortened significantly on the affected side compared with the contralateral side, these measurements did not correlate with the presence or absence of pain. AKP and functional knee scores after tibia IM nailing using a transtendinous approach were not associated with nail position in relation to the anterior tibial cortex or tibial plateau. LEVEL OF EVIDENCE: Level 3 (Case control study).

Comparison of intra-articular bupivacaine-morphine with bupivacaine-tenoxicam combinations on post-operative analgesia in patients with arthroscopic meniscectomy: a prospective, randomised study.

AIM: There are many alternatives for post-operative pain relief in patients who have had general anaesthesia. The aim of this study was to evaluate the efficacy of intra-articular bupivacaine + morphine and bupivacaine + tenoxicam applications in post-operative pain control in patients undergoing knee arthroscopy with general anaesthesia. METHOD: This was a prospective study. Standard anaesthesia procedures were applied to each patient, and the 240 patients chosen at random were then divided into two groups. Each group received a different combination of drugs for this double-blind study. The first group (group A: 120 patients) received 0.5% bupivacaine 100 mg + tenoxicam 20 mg (22 ml); the second group (group B) received 0.5% bupivacaine 100 mg + morphine 2 mg (22 ml); both groups received their drugs at the end of the intra-articular operation before tourniquet deflation. Before the operation, patients were asked about their post-operative pain at particular periods over the following 24 hours using the visual analogue scale (VAS) and the numeric rating scale (NRS). An additional analgaesic requirement and possible side effects were also recorded. RESULTS: Group A patients needed analgaesics sooner after operation than patients in group B. In Group B, VAS and NRS values were statistically higher compared with group A at the 12th hour. There were also fewer side effects seen in group A versus group B. CONCLUSION: Effective and reliable results were obtained in post-operative pain control in bupivacaine added to the morphine or tenoxicam groups following arthroscopic meniscectomy. In the tenoxicam group, patients reported less pain, fewer side effects and less need for analgesics at 12 hours after the operation. LEVEL OF EVIDENCE: level 1, therapeutic, randomised, multicentric study.

Rhabdomyolysis after tourniquet use in proximal tibial osteotomy: a case report and review of the literature.

Rhabdomyolysis following pneumotic tourniquet use is an extremely rare complication. In this case report, we aimed to present an unusual tourniquet complication following proximal tibial osteotomy. A 55-year-old female patient was operated on for genu varum in our clinic. Postoperatively, an anuria developed, and liver and kidney function test levels increased. The patient was diagnosed with acute rhabdomyolysis, and an aggressive treatment was begun.

Do PFNA devices and Intertan nails both have the same effects in the treatment of trochanteric fractures? A prospective clinical study.

OBJECTIVE: To clinically and radiologically compare third-generation intramedullary nails used in the treatment of trochanteric hip fractures and to determine their efficacy. MATERIALS AND METHODS: Seventy-five of 88 patients admitted to our hospital with trochanteric fractures were enrolled in the study; 43 were treated with PFNA devices and 32 with Intertan nails. The amount of compression applied during the procedure, duration of the procedure, amount of subsequent shortening in the proximal femoral area, subsequent backup of proximal screws, and changes in the tip-apex and tip-cortex distances were compared between groups. The postoperative change in the varus angle of the proximal femur and times to mobilization, full weight bearing, and fracture union were also evaluated. RESULTS: On early postoperative radiographs, the tip-apex distance was ≤25 mm in 86 % of patients in the PFNA group and 96.9 % of those in the Intertan group. Twelve months postoperatively, the tip-apex distance did not differ between groups. No cut-out of the screws into the coxofemoral joint was observed. Fracture healing was achieved in all patients. At 12 months postoperatively, the rates of proximal screw backup, proximal femoral shortening, and decrease in the varus angle of the proximal femur were significantly higher in the PFNA group than in the Intertan group. CONCLUSIONS: Trochanteric fractures may be treated effectively with PFNA devices or Intertan nails. During the healing period, the rates of reverse displacement of the proximal screw, shortening of the proximal femur, and decrease in the varus angle of the proximal femur were significantly higher in the PFNA group than in the Intertan group. Surgical technique, implant positioning, and the choice of implant play roles in the successful treatment of trochanteric fractures. LEVEL OF EVIDENCE: Level 1, prospective, prognostic study.

A modified surgical approach of the hip in children: is it safe and reliable in patients with developmental hip dysplasia?

PURPOSE: Treatment is easier and complications are less likely to occur if developmental dysplasia of the hip (DDH) is diagnosed early. In this study, we examined the early results of open reduction using a medial approach which we had modified for DDH and analyzed the success of this technique and the associated complication rates, with a focus on avascular necrosis (AVN). METHODS: This is an Institutional Review Board-approved retrospective review of all patients diagnosed with DDH and treated with a modified medial approach at a single institution from July 1999 to December 2010. The patients' charts were analyzed for clinical and radiographic features. RESULTS: Fifty-five hips of 41 patients, all of whom were treated by open reduction using a modified medial approach due to DDH, were evaluated retrospectively. The mean age of the patients at surgery was 19 (range 11-28) months, and the average follow-up was 5.5 (range 3-9.5) years. AVN was the most important complication in terms of radiological outcomes as assessed according to the Kalamchi-McEwen classification. Radiologic results were excellent or good in 51 hips (92.7 %) and fair-plus in four (7.3 %). Type 1 temporary AVN was detected in only two hips (3.6 %), and the lesions had disappeared completely in the final control graphs of these two patients. A secondary intervention was needed for two hips (3.6 %) of the same patients who were operated on due to bilateral DDH. No other complications, such as infection, re-dislocation, or subluxation, were seen in the operated patients. CONCLUSIONS: We believe that treatment for DDH using a modified medial approach during early childhood is an effective and reliable method with low AVN rates. As shown here, this method achieves great success in radiological and clinical outcomes after a minimum 3-year follow-up.

Arthroscopy-assisted treatment of Hoffa fracture associated with ipsilateral femoral shaft, tibial eminence and Malgaigne fractures.

Hoffa fracture associated with ipsilateral femoral shaft fractures is a rare clinical entity. We present a previously unreported multi-trauma case with a unique fracture combination of ipsilateral Hoffa, tibial eminence, femoral shaft and Malgaigne fractures. The Malgaigne fracture was treated non-operatively while the other three fractures were operated with arthroscopic and assisted techniques. Despite the use of minimally invasive techniques, the patient experienced postoperative soft tissue problems. In follow-up, all fractures healed with a good functional outcome. The application of a minimally invasive technique in such a high-energy trauma is crucial for prevention of soft tissue complications.

Effect of N-butyl cyanoacrylate on fracture healing in segmental rat tibia fracture model.

BACKGROUND: Comminuted fractures can occur due to severe traumas. The treatment of these fractures that may cause serious morbidity and sometimes mortality is N-butyl cyanoacrylate. It has been reported that this adhesive provides sufficient rigid fixation for bone healing. This study aims to examine cyanoacrylate radiologically and histologically to determine whether it provides adequate recovery in segmental fractures. The secondary objective is to evaluate N-butyl cyanoacrylate, an adhesive material that can hold the fragments on the fracture line together following reduction. METHODS: Sixteen Sprague-Dawley rats were divided in two groups as control (n = 8) and experimental (n = 8) groups. In the control group, segmental fractures were made and fixated with K-wire. In the experimental group, the same surgical procedure was applied and also fragments were stabilized with N-butyl cyanoacrylate. RESULTS: On the sixth week, we did not see any statistically significant difference in the radiological scoring between groups. However, the pathological scores of the control group were statistically higher than the cyanoacrylate group. CONCLUSIONS: We found that cyanoacrylate was rapidly and easily applied in the segmental fractures but did not cause any superior radiological and clinical results compared to the control group. The cyanoacrylate had low viscosity, and it was not capable enough to fill the defects formed between osteotomy surfaces. However, it did not adversely affect fracture healing as seen in biopsies taken as a result of follow-ups.

Association between attention deficit and hyperactivity disorder and Perthes disease.

OBJECTIVE: The aim of this study was to determine whether or not there is an association between attention deficit and hyperactivity disorder (ADHD) and Perthes disease. METHODS: The study included 3 groups of patients: Perthes patients, trauma patients, and orthopedic patients without Perthes disease or history of trauma. Each group was comprised of 56 males and 4 females. Patients were evaluated for present or past diseases, exposure to second-hand smoke, the age at which they had begun to walk, history of trauma prior to Perthes diagnosis in the Perthes group, weight, height and body mass index (BMI). Eighteen questions on the DSM-4 (Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition) ADHD checklist was used in the psychiatric evaluation of patients. The rate of ADHD was compared between groups. RESULTS: Attention deficit and hyperactivity disorder was diagnosed in 7 patients in the Perthes group, 3 in the trauma group, and 3 in the non-trauma group; and this difference was not significant (p=0.160). CONCLUSION: There were no significant differences in the rate of ADHD between trauma and non-trauma groups of Perthes patients, which suggests no association between ADHD and Perthes disease.

The relationship between intra-articular meniscal, chondral, and ACL lesions: finding from 1,774 knee arthroscopy patients and evaluation by gender.

Knowing the relationship between diagnoses is important in knee arthroscopy in terms of defining possible treatment modalities preoperatively. The purpose of our study was to define the diagnoses made intraoperatively through knee arthroscopy and the relationships between them. We evaluated the results of knee arthroscopies performed over a 10-year period. The sites and sizes of chondral lesions, the existence of anterior cruciate ligament (ACL) injury, and the sites of meniscal lesions were noted for a total of 1,774 patients. The relationships between these lesions were evaluated statistically. Chondral lesions and posterior medial meniscal tears were predominant in females, whereas complete ACL tears were predominant in males. ACL tears were commonly accompanied by medial and lateral meniscal bucket-handle tears. In cases with advanced chondral lesions, medial and lateral posterior meniscal and lateral anterior meniscal tears were more common. According to our results, posterior tears of the medial menisci, medial and lateral femoral condyles, lateral tibial plateau type 3 or 4 cartilage lesions, and the rate of diagnostic arthroscopy were higher in females, while middle substance and bucket-handle tears of medial menisci and total rupture of the ACL were more common in males. ACL injuries were seen to coexist with medial or lateral menisci bucket-handle tears, with no relationship between the site or size of the chondral lesions. A relationship between medial and lateral meniscal tears and the site of femoral and tibial chondral surface lesions was detected.

Factors influencing outcome of knee bone marrow oedema: a clinical study.

Bone marrow oedema has a long recovery time. Conservative and surgical treatments have been used. This study aimed at identifying a profile of patients who may benefit from nonsurgical management. We compared the results of periodic clinical and radiological examinations of patients who visited our clinic with knee pain and were diagnosed with bone marrow oedema following magnetic resonance imaging (MRI) examinations. Clinically, the patients were evaluated using the Lysholm knee score and a visual analogue scale. The study included 67 patients (31 males, 36 females) who were followed for 6-24 months. Patient age, gender, body mass index, affected area, and concomitant intra-articular pathology were analysed. Of the 67 patients, 63 were treated conservatively, and four underwent decompression. Patients with involvement of both the medial femoral condyle and tibial plateau were found to be more resistant to treatment than those in which only the tibial plateau was affected. Intra-articular pathologies were frequently noted together with bone marrow oedema, causing knee pain to persist after the bone marrow oedema had subsided.

Osteoid osteoma of the great toe mimicking osteomyelitis: a case report and review of the literature.

Osteoid osteomas are well-known benign tumors, seen generally in long bones. When seen in phalanxes or toes, they can cause a diagnostic dilemma. A young male presented to us with complaints of enlargement of the great toe and severe pain. He had had an ingrown toe-nail operation before, and this situation caused a diagnostic dilemma. In this case report, we emphasize that osteoid osteomas can cause diagnostic dilemmas and it should be kept in mind as a differential diagnosis.

Intramedullary nailing versus percutaneous locked plating of distal extra-articular tibial fractures: a retrospective study.

The aim of this study is to compare distal tibial fractures (4-10 cm proximal to the plafond) treated by intramedullary nailing with those treated by percutaneous locked plating and to assess the clinical and radiographic results, complication rates, and the need for secondary procedures. Thirty-six patients received percutaneous locked plate treatment and 25 patients received intramedullary nail treatment. The results obtained from these two treatment methods were assessed by comparing infection rates, starting time for wight-bearing, local implant irritation, union and malunion rates and along with secondary procedures. In the percutaneous locked plate group, two deep infections, four superficial infections, two nonunions, one malunion and 10 local implant irritations were observed. In the intramedullary nail group, one nonunion, four malunions and two local implant irritations were observed. The incidence of deep and superficial infections, local implant irritations and secondary procedures in the percutaneous locked plate group was greater than those in the intramedullary nail group. The time to full weight bearing was shorter in the intramedullary nail group. There was no significant statistical difference in malunion and nonunion rates between the two groups. The need for secondary procedures was more common in group receiving the percutaneous locked plate treatment and the time to full weight bearing was shorter in the intramedullary nail group.

[Long-term use of fondaparinux in major orthopedic surgery]. / Fondaparinuksun majör ortopedik cerrahide uzun süreli kullanimi.

OBJECTIVES: This study aims to investigate whether the usage of fondaparinux sodium may result in major hemorrhages following major orthopedic surgery. PATIENTS AND METHODS: Forty-three patients (30 females and 13 males; mean age 66 years; range 34 to 94 years) at the age of >18 years who were scheduled for major orthopedic surgery were included. Total hip arthroplasty, total knee arthroplasty and proximal femur fracture surgeries were defined as the major orthopedic surgeries. Prophylaxis was administered with 2.5 mg fondaparinux sodium once daily subcutaneously. Prophylaxis was initiated at 6-8 hours after the closure of incision. During the prophylaxis period (31±3 days), the patients were monitored for symptomatic deep venous thrombosis. Serum creatinine, platelet and hemoglobin levels were measured at the baseline and in the first week and at one month postoperatively. Wound healing time, healing complications, and major/minor hemorrhages seen during the prophylaxis period were recorded. RESULTS: During the follow-up, none of the patients had symptomatic deep vein thrombosis or symptomatic pulmonary embolism. Two patients (4.6%) had delayed wound healing, while four (9.3%) had minor ecchymosis. No major hemorrhages were observed in any patients. CONCLUSION: With the long-term use of fondaparinux, we did not observe any major hemorrhagic complications. However, further large-scale studies including control groups are required to establish the effects of long-term use of fondaparinux.

Comparison of reduction methods in intramedullary nailing of subtrochanteric femoral fractures.

OBJECTIVE: The aim of this study was to compare the outcomes of three reduction methods used during intramedullary nailing of the subtrochanteric femur fractures. METHODS: This study included 45 patients with subtrochanteric femur fractures who were treated with intramedullary nailing. Twenty-two patients underwent clamp-assisted reduction, 11 reduction with cable cerclage, and 12 with blocking screws. Reduction techniques were compared with respect to the early postoperative alignment, one year postoperative alignment, time to full weight-bearing, time to union, Harris hip score at one year, operation and fluoroscopy times, blood transfusion amount, complications, and additional interventions. RESULTS: The clamp-assisted reduction group had a statistically high mean time to full weight-bearing (p=0.038) and a low mean Harris hip score at one year (p=0.002). The blocking screw group's operation times and fluoroscopy times were statistically long. There was no statistically significant difference between the clamp-assisted reduction and cable cerclage groups in terms of operation times and fluoroscopy times. On the other hand, there were statistically significant differences between the clamp-assisted reduction and blocking screw groups (p=0.0001 and p=0.0001, respectively) and between the cable cerclage and blocking screw groups (p=0.037 p=0.0001, respectively) in terms of operation times and fluoroscopy times. There was no statistically significant difference between the clamp-assisted reduction, cable cerclage and the blocking screw groups in terms of early postoperative alignment, one year postoperative alignment, time to union, complications or additional interventions. CONCLUSION: Clamp-assisted reduction leads to a longer time to weight-bearing and a poorer functional status at one year. Operation time and fluoroscopy time were longest in the blocking screw group.

Suprascapular nerve block for the treatment of frozen shoulder.

AIMS: The aim of our study was to compare the effects of suprascapular nerve block in patients with frozen shoulder and diabetes mellitus unresponsive to intraarticular steroid injections. SETTINGS AND DESIGN: Ten patients without improvement of sign and symptoms after intraarticular injections were made a suprascapular nerve block. METHODS: Pain levels and active range of movement of patients were recorded at initial attendance and after 1, 4, and 12 weeks. All patients' simple pain scores, total pain scores, and range of motion of their shoulders were improved significantly after suprascapular nerve block. STATISTICAL ANALYSIS: In this study, the statistical analyses were performed by using the SPSS 8.0 program (SPSS Software, SPSS Inc., USA). To compare pre- and post-injection results of simple pain score, total pain score, shoulder abduction and external rotation, Wilcoxon test was used. RESULTS: Patient's simple pain scores, total pain scores also abduction, external rotation and internal rotation angles were improved significantly after suprascapular nerve block. CONCLUSION: Effective results after suprascapular nerve blockage was obtained for the treatment of refractory frozen shoulder cases.

Minimally invasive reduction technique in split depression type tibial pilon fractures.

Tibial pilon fractures usually result from high energy trauma and present as a challenge to the orthopedic surgeon. Accurate reduction of the joint with meticulous care for the surrounding soft tissues is mandatory. We present a case report in which an anterior cruciate ligament targeting device is used with a minimally invasive technique under arthroscopic and fluoroscopic guidance for Orthopaedic Trauma Association 43-B2.3 type pilon fracture treatment.

Proximal medial tibial biplanar retrotubercle open wedge osteotomy in medial knee arthrosis.

The patellar tendon length changes and patella infera occurs in medial open wedge osteotomies. We hypothesized that patellar tendon length in the sagittal plane would not change in a proximal medial tibial biplanar retrotubercle open wedge osteotomy. Proximal medial tibial biplanar retrotubercle open wedge osteotomies were conducted on 23 knees of 22 patients; the mean patient age was 59 ± 7 years (range, 53-69 years). The surgical procedure used had some technical distinctions from those used in literature. The mean follow-up was 37 ± 11 months (range, 19-58 months). Preoperative and postoperative Hospital for Special Surgery Scoring System (HSS) scores, radiological tibial slope, Insall-Salvati, Blackburne-Peel, and Caton indices, femoro-tibial anatomical axis angle, the angle between the femoral condyle and tibial plateau, and the angle between the tibial plateau and tibial axis were measured and compared statistically. Postoperative HSS scores were statistically higher than the preoperative HSS scores. The femoro-tibial axis angle, the angle between the femoral condyle and tibial plateau, and the angle between the tibial plateau and tibial axes decreased significantly. No statistical difference was observed between the preoperative and postoperative Insall-Salvati, Blackburne-Peel, or Caton indices. When we performed proximal medial tibial biplanar retrotubercle open wedge osteotomy, clinical and radiological recovery was observed but patellar height did not change.

Suction drainage influence on knee effusion following partial meniscectomy with partial fat pad or synovium resection.

OBJECTIVE: The aim of our study was to examine the effect of suction drains on knee after arthroscopic partial meniscectomy with partial fat pad removal or synovectomy. METHODS: We performed arthroscopic partial meniscectomy for posterior tears of the medial meniscus and partial fat pad or synovium shaving in 72 patients. Following surgery, a suction drain was not used in 40 patients (Group A) and used in 32 (Group B). Both groups were similar in terms of age, gender, and total operation time. The patients were evaluated at 1, 2, and 4 weeks postoperatively for the presence of a knee effusion. RESULTS: No significant difference was observed in the grade of effusion and the average percent change in the effusion grade between Groups A and B at 1, 2, and 4 weeks postoperatively. CONCLUSION: Use of a suction drain did not influence the postoperative effusion or the clinical course of the effusion after arthroscopic partial meniscectomy with partial fat pad removal or synovectomy.

Anatomical frame plate osteosynthesis in Ada-Miller Type 2 or 4 scapula fractures.

OBJECTIVES: The aim of this prospective study was to evaluate the results of anatomical frame plate osteosynthesis in patients with Ada and Miller Type 2 or 4 scapula fractures. METHODS: Eleven Ada and Miller Type 2 or 4 scapula fractures in nine patients were treated with anatomical frame plate osteosynthesis. The mean follow-up time was 39.8 (12-77) months. The results were evaluated using the Herscovici score. RESULTS: No complications, such as neurovascular injury, postoperative hematoma, infection, delayed wound healing, implant failure, delayed union, or nonunion occurred. Based on the Herscovici score, the results were excellent. CONCLUSION: Osteosynthesis with anatomical frame plates appears to be a safe method that allows early range of motion and that provides excellent results in Ada and Miller Type 2 or 4 scapula fractures.