Dry needling in lateral epicondylitis: a prospective controlled study.

PURPOSE: Lateral epicondylitis (LE), a common disease, especially in middle age, causes decreased productivity and economic losses. The first-line treatment for LE is conservative and consists of topical and oral anti-inflammatory drugs, ice application, and brace use. If the first-line treatment fails, second-line treatment modalities, which are generally invasive, are offered. Second-line therapeutic regimens include saline, corticosteroid, or platelet-rich plasma injections. Dry needling is relatively new. We hypothesized that dry needling would be at least as effective as first-line treatment for LE. We compared the outcomes of first-line treatment and dry needling. METHODS: The study allocated 110 patients into groups using online randomization software. After completing the Patient-rated Tennis Elbow Evaluation (PRTEE), patients in group I received dry needling, whereas those in group II received first-line treatment, consisting of ibuprofen 100 mg twice a day and a proximal forearm brace. The patients were evaluated after three weeks and six months. RESULTS: The study ultimately analyzed 92 patients. Although both treatment methods were effective at three weeks, dry needling was significantly more effective than the first-line treatment at six months. CONCLUSION: Because of the low complication rate, dry needling is a safe method, and it might be an effective treatment option for LE.

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.

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.

Can the complications of distal locking be prevented with a new nail that offers a novel locking technique in the treatment of humeral shaft fractures?

OBJECTIVES: This study aims to investigate whether complications related to distal locking can be prevented with InSafeLOCK® nail in the treatment of humeral shaft fractures. PATIENTS AND METHODS: Hospital records of 31 patients (15 males, 16 females; mean age 54.4±10.1 years; range, 20 to 86 years) treated with InSafeLOCK® nail for humeral shaft fractures were investigated retrospectively between February 2016 and January 2019. Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification was used to determine the type of fracture. During the implementation, the elapsed time for distal locking was investigated. Complications encountered during both implementation and postoperative follow-up were investigated. RESULTS: Fourteen of the fractures were type A, 12 were type B, and five were type C. The mean follow-up time was 18.2 (range, 6 to 30.5) months. The mean duration for distal locking was 2.1 (range, 1.2 to 3.1) minutes. In one (3.2%) patient, cortical penetration occurred at the anterior cortex of the humerus at distal to the nail. In one patient, nail breakage occurred at the distal part of the nail. In one patient, rotational instability occurred due to screw loosening. CONCLUSION: InSafeLOCK® humeral nail is safe when applied with the recommended technique. It can easily be applied without damaging the veins, nerves or other soft tissues around the elbow due to the internal distal locking feature; furthermore, there is no need to use fluoroscopy or targeting guide. Thus, it is possible to avoid complications that may occur during and after distal locking in conventional intramedullary nail implementations.

Effect of Repeated Sterilization by Different Methods on Strength of Carbon Fiber Rods Used in External Fixator Systems.

OBJECTIVES: We aimed to study the effects of repeated sterilization, using different methods, on the carbon fiber rods of external fixator systems. METHODS: We used a randomized set of 44 unused, unsterilized, and identical carbon fiber rods (11 × 200 mm), randomly assigned to 2 groups: unsterilized (4 rods) and sterilized (40 rods). The sterilized rods were divided into 2 groups, those sterilized in an autoclave and those sterilized using hydrogen peroxide. These were further divided into 5 subgroups based on the number of sterilization repetition to which the fibers were subjected (25, 50, 75, 100, and 200). A bending test was conducted to measure the maximum bending force, maximum deflection, flexural strength, maximum bending moment and bending rigidity. We also measured the surface roughness of the rods. RESULTS: An increase in the number of sterilization repetition led to a decrease in maximum bending force, maximum bending moment, flexural strength, and bending rigidity, but increased maximum deflection and surface roughness (P < 0.01). The effect of the number of sterilization repetition was more prominent in the hydrogen peroxide group. CONCLUSIONS: This study revealed that the sterilization method and number of sterilization repetition influence the strength of the carbon fiber rods. Increasing the number of sterilization repetition degrades the strength and roughness of the rods.

Radiological and clinical outcomes of medial approach open reduction by using two intervals in developmental dysplasia of the hip.

OBJECTIVE: To evaluate the midterm clinical and radiological outcomes of the medial approach using two intervals for developmental hip dysplasia (DDH). METHODS: The study involved 62 hips of 47 patients (41 girls, 6 boys) treated with medial approach for DDH from 1999 to 2010. The age of the patients at surgery was 18.7 ± 2.25 months. Follow up of the patients was 11.3 ± 3.07 years. The age of the patients at the last follow up was 12.6 ± 1.74 years. According to the Tönnis classification, 13 hips were grade II, 27 hips were grade III and 22 hips were grade IV. Patients were evaluated according to Omeroglu radiological criteria and modified McKay functional criteria. The presence of avascular necrosis (AVN) of the hip was questioned using the KalamchiMacEwen classification. RESULTS: Radiologically, forty eight (77%) hips were evaluated as "excellent", 8 (13%) hips as "good" and 5 (8%) hips as "fair plus" and 1 (%2) hip as "fair minus". Two (3%) patients had type 1 temporary AVN and one (1%) patient had type 4 AVN with coxa magna and overgrowth of the greater trochanter. According to McKay functional criteria, 56 (90%) hips had "excellent" and 6 (10%) had "good" results. Two (3.2%) hips of one patient had to be reoperated with Salter osteotomy and femoral shortening + derotation osteotomy. CONCLUSION: Medial approach using two separate intervals for tenotomy and capsulotomy does not jeopardize the medial circumflex or the femoral vessels and yields satisfactory midterm results for children 18 months old with dysplasia of the hip. LEVEL OF EVIDENCE: Level IV, therapeutic study.

[Extracorporeal shock wave therapy in patients with lateral epicondylitis]. / Lateral epikondilitli olgularda ekstrakorporeal sok dalga tedavisi.

OBJECTIVES: We investigated the effect of extracorporeal shock wave therapy in the treatment of lateral epicondylitis. METHODS: The study included 13 elbows of 12 patients (8 women, 4 men; mean age 40 years) who did not benefit from conservative therapy for lateral epicondylitis and refused surgical therapy. Under fluoroscopic guidance, extracorporeal shock wave therapy of 1200 pulses at 15-20 kV was administered at a mean of three sessions (range 3 to 7 sessions) with two-day intervals. No immobilization was applied after sessions. The patients were questioned about pain during rest and during dorsiflexion of the wrist against resistance before and after three and 12 months of treatment. The results were evaluated using the Roles and Maudsley pain scores. At the end of 12 months, the patients were asked to lift weight with the shoulder in flexion and the wrist in extension to measure grip strengths in comparison with the unaffected side. RESULTS: The mean pain score which was 3.4 before treatment decreased to 2 after treatment. The mean grip strength of the affected extremities was 82.1% of the normal side. At final follow-ups, nine patients (10 elbows) (75%) stated that the treatment was beneficial; all these patients achieved at least 85% of grip strength of the normal side. Two patients (16.7%) reported no benefit from therapy and had a poor pain score. The result was fair in one patient (8.3%) who expressed dissatisfaction and had partial relief after the procedure. This patient achieved 60% of grip strength of the unaffected side. CONCLUSION: Extracorporeal shock wave therapy is an alternative method for patients who do not benefit from conservative treatment and refuse surgical treatment.

[The effect of risedronate treatment on bone turnover markers in patients with hip fracture]. / Kalça kiriklarinda risedronat tedavisinin kemik yikim ürünlerine etkisi.

OBJECTIVES: The effect of risedronate treatment on bone resorption was investigated quantitatively by measuring N-telopeptide levels in urine of patients with hip fracture. METHODS: Forty-six women (mean age 75 years) who underwent surgical treatment for intertrochanteric or femoral neck fractures due to minor trauma were divided into two groups according to the order of presentation. One group (26 patients; mean age 77+/-5 years) received oral risedronate 5 mg/day after the fifth postoperative day, while the other group (20 patients; mean age 73+/-6 years) received no drug treatment. Patients who had been on treatment for Paget's disease or osteoporosis or those with renal failure were excluded. Urine samples were collected from all the patients on the second day of hospitalization and at the end of three months to measure N-telopeptide levels, one of the bone turnover markers, with the use of the Osteomark NTx ELISA laboratory kit. RESULTS: The mean urine N-telopeptide level decreased by 49.7% at the end of three months of treatment with risedronate (p<0.0001), whereas there was a 5.8% increase in the N-telopeptide level of the control group. The two groups differed significantly with respect to the levels of bone resorption at the end of three months (p<0.0001). CONCLUSION: Risedronate treatment was found effective in decreasing bone resorption and thus in reducing the risk for refractures in patients with hip fractures due to minor trauma.

Arthroscopic Technique for Treatment of Schatzker Type III Tibia Plateau Fractures Without Fluoroscopy.

Accurate reduction and maintenance of the stability with correct implant positioning is critical for surgical treatment of tibial plateau fractures. Our technique includes an arthroscopic reduction and fixation of Schatzker type III tibial plateau fractures with a bulls-eye screw placement without fluoroscopy control. With the arthroscopic guidance, an anterior cruciate ligament drill guide is placed and a K-wire sent to the midpoint of the depressed fragment through the guide at a 40° angle to the coronal axis of the tibia. A tunnel is created with the drill over the K-wire. The depressed fragment is further augmented with gentle impacts over the K-wire. After arthroscopic reduction control, an appropriate-sized iliac graft is pushed until it is below the depressed fragment. The targeting device is adjusted at 130° so that it is parallel to the joint line and a K-wire sent through the device so that it would pass just below the graft. The graft is then supported with cannulated screws sent over the K-wire. This technique provides an arthroscopic reduction of the chondral surface and precise placement of the rafting screws without fluoroscopy.

Effect of bleeding on nerve regeneration and epineural scar formation in rat sciatic nerves: an experimental study.

OBJECTIVE: Epineural scar formation is one of the most significant negative factors affecting surgical repair after peripheral nerve injury. The scar tissue mechanically hinders axonal regeneration and causes adhesions between nerves and surrounding tissues. A hemostatic agent Ankaferd Blood Stopper (ABS; Immun Gida Ilaç Kozmetik San. ve Tic. Ltd. Sti., Istanbul, Turkey) has not been previously used. Decreasing the postoperative bleeding and adhesions between nerve and surrounding tissues will prevent the formation of scar tissue, as well as corresponding compressive neuropathy and/or deceleration of axonal regeneration. The purpose of this experimental study was to investigate the effects of bleeding on nerve healing and scar tissue after repair of peripheral nerve injuries. METHODS: The right sciatic nerve of 30 Sprague-Dawley male rats (weighing 260-330 g) was cut 1.5 cm proximal to the trifurcation and repaired primarily with 8/0 sutures using epineural technique. The rats were then divided into 3 groups. Saline was applied in Group 1 (n=10), ABS in Group 2 (n=10), and heparin in Group 3 (n=10) for 5 minutes to the repair site and surrounding tissues. In each group, electrophysiological measurements were performed with electromyography (EMG) at postoperative week 12. Magnetic resonance diffusion tensor imaging was used at week 12. Macroscopical and histopathological evaluations were conducted after sacrificing the rats at week 24 with total excision of the repaired sciatic nerves and surrounding tissues. RESULTS: The ABS and saline groups showed better healing than the heparin group. The ABS and saline groups were better in the histopathologic evaluations, but there was no statistically significant difference between the 2 groups. CONCLUSION: Statistically significant differences were not found between the 3 groups. Significant results may be obtained with larger studies.

Mid-term radiological and clinical results of incomplete triple pelvic osteotomy.

OBJECTIVE: The aim of this study was to assess clinical and radiological results of incomplete triple pelvic osteotomy in acetabular dysplasia. PATIENTS AND METHODS: Twenty-six hips of 24 patients (5 males, 19 females) treated with incomplete triple pelvic osteotomy by a single surgeon from February 1995 to October 2001 were retrospectively reviewed at an average follow-up time of 12 years. The mean age at the time of surgery was 21.6 years (range: 14-41). Radiological evaluation was based on the central edge angle, acetabular angle, acetabular index, acetabular head index and lateralisation. Clinical and radiological scoring was performed using the Harris scoring system, Ömeroglu scoring system and the Tönnis criteria for osteoarthritis. RESULTS: There was significant improvements in all of the radiological parameters with 88.5% good radiological results, 96.2% excellent clinical results, no significant progression to osteoarthritis and no need for conversion to total hip arthroplasty. The rate of major complication was 11%. Retroversion was seen in 15.4% of the hips. CONCLUSION: Our results support the use of incomplete triple pelvic osteotomy as a safe choice in the treatment of acetabular dysplasia as it offers clinical and radiological benefits and contributes to the prevention of osteoarthritis. LEVEL OF EVIDENCE: Level IV, therapeutic study.

[Comparison between the lateral and medial approaches in terms of functional and cosmetic results in the surgical treatment of type III supracondylar humeral fractures in children]. / Cocuklarda suprakondiler humerus tip III kiriklarin tedavisinde lateral ve medial girisimler ile cerrahi tedavi sonuçlarinin fonksiyonel ve kozmetik açidan karsilastirilmasi.

OBJECTIVES: We compared the functional and cosmetic results of lateral and medial approaches in the surgical treatment of type III supracondylar humeral fractures in children. METHODS: The study included two groups in which type III supracondylar humeral fractures were treated using either lateral (12 boys, 8 girls; mean age 7.2 years; range 4 to 12 years) or medial (16 boys, 4 girls; mean age 7.4 years; range 3 to 11 years) approaches and internal fixation. Functional and cosmetic results were assessed according to the criteria proposed by Flynn et al. The mean follow-up periods were 19.8 months (range 8 to 30 months) and 19.5 months (range 12 to 27 months) in the lateral and medial approach groups, respectively. Patient satisfaction was also inquired regarding the site of the incision scar. RESULTS: In the lateral approach group, functional results were excellent in 18 patients (90%), good in one patient (5%), and fair in one patient, while cosmetic results were excellent in 19 patients (95%) and good in one patient. In the medial approach group, 19 patients (95%) had excellent and one patient (5%) had good functional results, while all the patients had an excellent cosmetic result (p>0.05). Complications were seen only in the lateral approach group, including transient ulnar nerve palsy in one patient, and cubitus varus deformity due to limited range of motion in another. The satisfaction rates concerning the site of the incision scar were 25% and 70% in the lateral and medial approach groups, respectively. CONCLUSION: Although no significant differences were found between the lateral and medial approaches in terms of functional and cosmetic results, the medial approach may be more convenient due to a lower risk for ulnar nerve injury and to a greater acceptability of the medial incision scar on the part of the patients.

Precise placement of lag screws in operative treatment of trochanteric femoral fractures with a new guide system.

PURPOSE: We assessed the accuracy of a new guide system that we developed to place lag screws in the proper position with the minimum number of attempts for operative treatment of trochanteric femoral fractures. METHODS: A total of 55 consecutive trochanteric femoral fractures were treated with a cephalomedullary nail. The first 27 consecutive patients were treated with the standard operation (group A), while the new guide system was used in the last 28 consecutive patients (group B). The numbers of attempts to place K wires and the duration of surgery were noted. Accuracy of lag screw placement was evaluated by measuring the angle of deviation from the central axis of the femoral head. RESULTS: Deviation values ranged from -11̊ to +15̊ for the 27 cases in group A, with a median absolute deviation of 8̊±6̊. That in the 28 cases after the introduction of the new guide system (group B) ranged from -5̊ to +6̊, with a median absolute deviation of 0.5̊±3̊ (P<0.001). The total numbers of attempts to place lag screws and mean operation time decreased significantly after introduction of the new guide system (P<0.001). CONCLUSIONS: With this new guide system, we are able to insert lag screws successfully in the optimal position even in most unstable fractures. The present study indicated that this new guide system and nail facilitate accurate placement of lag screws in the appropriate position with the minimum number of attempts.

Rare inferior shoulder dislocation (luxatio erecta).

Although shoulder dislocations have been seen very frequently, inferior dislocation of shoulder constitutes only 0.5% of all shoulder dislocations. We share our 4 patients with luxatio erecta and present their last clinical control. 2 male and 2 female Caucasian patients were diagnosed as luxatio erecta. Patients' ages were 78, 62, 65, and 76. All patients' reduction was done by traction-abduction and contour traction maneuver in the operating room. The patients had no symptoms and no limitation of range of motion of their shoulder at their last control. Luxatio erecta is seen rarely, and these patients may have neurovascular injury. These patients should be carefully examined and treated by the orthopaedic and traumatology surgeons.

Developmental dysplasia of the hip associated with aplasia of the pubic bone (hook-pelvis): report of a case and review of the literature.

Aplasia of the pubic bone associated with congenital hip dislocation is rare. Various dysmorphic conditions featuring absence or hypoplasia of the ischiopubic bone, associated with congenital hip dislocation, have been distinguished in the literature. We report the case of an 18-month-old boy with developmental dysplasia of the hip associated with isolated total aplasia of the pubic bone. Patient was successfully treated with modified Salter osteotomy and reverse U-shaped capsuloplasty.

Deep venous thrombosis and pulmonary embolism as rare complications after hallux valgus surgery: case report and literature review.

The incidence and life-threatening complications of thromboembolic disease after major orthopedic surgical procedures have been extensively defined in the medical literature. However, there are few studies concerning the incidence of thromboembolic disease after foot and ankle surgery. We describe a 57-year-old female patient who underwent surgery for bilateral hallux valgus deformities and was diagnosed as having deep venous thrombosis and pulmonary embolism after the surgery despite early mobilization and mechanical prohylaxis. Her preoperative physical examination revealed varicose veins in both cruris. She was treated for pulmonary embolism with low-molecular-weight heparin and an oral anticoagulant in the postoperative period. Although venous thromboembolism is more commonly described after proximal lower-extremity procedures, it can occur after foot and ankle surgery, particularly if the patient has certain risk factors. Therefore, in addition to mechanical prophylaxis, pharmacologic prophylaxis should be kept in mind in such patients.

Closed total talar extrusion after ankle sprain.

Closed total talus dislocation from tibiotalar, subtalar, and talonavicular joints is a very rare injury. A 25-year-old young man, who had severe ankle distortion while walking down a flight of stairs, was brought to the emergency room complaining of a deformity and pain in his ankle joint. Roentgenographies revealed total talar body extrusion. The patient was treated urgently with open reduction in the authors' clinic. Tibialis posterior tendon might prevent closed reduction so open reduction with retraction of the tendon may be necessary.