An investigation into the frequency and risk factors of low back pain following surgical treatment of isolated calcaneal fractures.

OBJECTIVE: This study aimed to determine the frequency of low back pain after calcaneal fractures treated with open reduction internal fixation (ORIF) and the risk factors that cause this condition. METHODS: Thirty-one patients (27 males and 4 females) who underwent surgery for a unilateral calcaneal fracture between 2016 and 2020 and had no complaints of low back pain before fracture surgery were included in the study. The patients were divided into 2 groups: those who developed low back pain after the operation and those who did not. Patients were evaluated with the Life Quality Short Form SF-36, the Oswestry Disability Index (ODI), and American Orthopedic Foot-Ankle Association Score (AOFAS). Sanders' fracture type, joint range of motion (ROM) measurements of injured and uninjured limbs, maximal isometric muscle strength measurements, balance on 1 leg with pedobarographic measurements, and walking time were evaluated. The obtained data were compared among the 2 groups. RESULTS: Low back pain was observed in 71% of the patients and was detected after an average of 6 months from the operation. In ODI, 59.1% of the patients reported that low back pain limited their lives slightly. Patients with low back pain have lower AOFAS scores and worse SF-36 physical functionality than those without low back pain (P < .001, P=.016). Balance time on 1 foot in pedobarographic measurements, foot in ROM, ankle in ankle active, passive plantar flexion, inversion, active hip, passive internal, external rotation, muscle is the foot eversion force. In these measurements, the values of the injured side are intact. It was statistically significantly lower than the other side (interaction P < .1). CONCLUSION: Low back pain may occur after unilateral calcaneal fractures treated by ORIF. This may be caused by decreased angles of ankle dorsi and plantar flexion, foot inversion, hip abduction, and internal and external rotation. In the rehabilitation program, not only the ankle region but also the hip joint of the affected side should be included, and the kinetic chain that describes the interaction mechanism of the human body should not be forgotten. LEVEL OF EVIDENCE: Level IV, Prognostic Study.

Management of complex pilon fractures: Is it necessary to fix all the columns in AO/OTA type 43-C fractures?

INTRODUCTION: Surgical treatment of AO/OTA 43-C pilon fractures has not yet taken a standard form. We aimed to evaluate whether patients that appeared to be labelled as unsupported columns according to the four-column theory would affect long-term clinical and radiological outcomes. MATERIALS AND METHODS: Patients with AO/OTA 43-C type who were treated surgically between January 2010 and December 2019 were included in the study. 53 fractures in 52 patients who received osteosynthesis were categorized based on the fixed columns. These groups were formed as fully supported columns (FSC- Group A), partly supported columns (PSC-Group B), Ankle range of motions (ROM), Burwell Charnley's reduction evaluation criteria, Kellgren-Lawrence ankle osteoarthritis staging system, and American Orthopedic Foot and Ankle Society (AOFAS) Scoring System, Olerud-Molander Ankle Score, Visual Analog Scale were used for evaluating radiological and functional outcomes. RESULTS: The mean follow-up period was 72.6 (12-131) months. Mean age was 42.6 (18-76). Two groups were homogenously distributed in terms of age (p = 0.785), sex (p = 0.376), laterality (p = 0.732), smoking status (p = 0.488) and reduction quality. There was no difference in AOFAS score (p = 0.452), Olerud-Molander score (p = 0.354) and VAS scores (p = 0.589). TAS, TLS and TT angle measurements suggested no difference between groups (p = 0.493, p = 0.834, p = 0.577). There was no difference between groups in terms of infection (p = 0.734), malunion (p = 0.688) and arthritis (p = 0.483) CONCLUSION: We presented findings that contradicted the hypothesis positing the existence of four distinct columns in pilon fractures, as well as the notion that each fractured column requires support from distinct implants. LEVEL OF EVIDENCE: Level III.

Simultaneous sequential anterolateral thigh free flaps with interposition comitant vein graft for one-stage lower extremity reconstruction: A case report.

Developments in the microsurgery have made perforator fasciocutaneous free flaps more popular in lower extremity reconstructions. They have acceptable donor site morbidities when compared to traditional methods. However; there are some possible limitations with these flaps such as anatomical variations and insufficiency to cover large and/or complex defects with a single flap. Anterolateral thigh flap (ALT), which has proven its advantages in the reconstruction of many regions of the body, is one of the versatile perforator fasciocutaneous flap options. We present our experience of using sequential double ALTs for complex lower extremity reconstruction. A 44-year-old patient, who had a history of multiple traumas as a result of a traffic accident, had interconnected anterior tibial (6 × 4 cm) and bimalleolar defects (4 × 4 cm, 4 × 5 cm) in his left lower extremity. Double ALT flaps (16 × 9 cm, 17 × 10 cm) were used to reconstruct three individual defects. The posterior tibial artery was the only uninjured artery perfusing the lower extremity, so the already occluded anterior tibial artery was chosen as the recipient to avoid disturbing the posterior tibial vessels. The dominant comitant vein of one of the flaps was leaving the pedicle too early and following an aberrant path with increased diameter. As it was understood that the other comitant vein had poor drainage, it was taken as an interposition vein graft to lengthen the dominant aberrant vein. The two flaps were customized as one by flow-through anastomoses on the operating table. The anterior tibial artery was washed and debrided distal to proximal until arterial spurting was seen. At the distance of 8 cm superior, the artery was found as feasible and anastomoses were performed. The proximal flap was inset vertically and the distal flap was inset on the horizontal axis to reach the bilateral malleolar defect. No complications were observed in both flaps. The patient was followed-up for 8 months. Despite the successful reconstruction, the patient is still unable to walk unaided due to multiple traumas and the rehabilitation process continues. We believe that the use of sequential double ALT may be a useful alternative to reconstruct large lower extremity defects with minimal donor site morbidity when a suitable single recipient vessel is available.

Is interferential current effective in the management of pain, range of motion, and edema following total knee arthroplasty surgery? A randomized double-blind controlled trial.

OBJECTIVE: To investigate the effectiveness of interferential current implementation following total knee arthroplasty surgery. DESIGN: Double-blind randomized controlled study. SETTING: Orthopedics and traumatology in-patient clinic. PARTICIPANTS: From an initial enrollment of 132 patients, 113 who met the study inclusion criteria were randomly separated into two groups: the interferential current group ( n = 57) and the sham current group ( n = 56). A total of 98 patients completed the study: 49 in the interferential current group and 49 in the sham group. INTERVENTION: Patients in the interferential current group received interferential current treatment for 30 minutes, twice a day for five days postoperatively. For the patients in the sham interferential current treatment group, the same pads were applied to the patients for the same time periods but no electrical stimulation was applied. MAIN OUTCOME MEASURES: Patients were assessed in respect of pain, range of motion (ROM), edema, and the amount of paracetamol used at baseline and on the 5th and 30th days after surgery. RESULTS: No significant difference was determined between the groups in respect of pain, ROM, and edema at days 0, 5, and 30. At the end of the 5th day, the amount of paracetamol used was significantly lower in the interferential current group ( P < 0.05). CONCLUSION: In this study, both groups showed significant improvements in pain, ROM, and edema with no significant difference between the groups. Although there was a significant difference in paracetamol intake of the two groups, this cannot be argued as showing the effectiveness of interferential current.

Single dose of intra-muscular platelet rich plasma reverses the increase in plasma iron levels in exercise-induced muscle damage: A pilot study.

BACKGROUND: Platelet rich plasma (PRP) therapy is widely used in enhancing the recovery of skeletal muscle from injury. However, the impact of intramuscular delivery of PRP on hematologic and biochemical responses has not been fully elucidated in exercise-induced muscle damage. The purpose of this investigation the effects of intramuscular delivery of PRP on hematologic and biochemical responses and recovery strategy muscle damage induced by high intensity muscle exercise (exercise-induced muscle damage, EIMD). METHODS: Moderately active male volunteers participated in this study and were assigned to a control group (control, n = 6) and PRP administration group (PRP, n = 6). The subjects performed exercise with a load of 80% one repetition maximum (1RM) maximal voluntary contraction of the elbow flexors until point of exhaustion of the non-dominant arm was reached. The arms were treated with saline or autologous PRP post-24 h EIMD. Venous blood samples were obtained in the morning to establish a baseline value and 1-4 days post-exercise and were analyzed for serum ferritin, iron, iron binding capacity (IBC), creatinine kinase (CK), lactate dehydrogenase (LDH), aspartate aminotransferase (AST), and alanine aminotransferase (ALT). RESULTS: The baseline levels of plasma iron, ferritin, IBC, CK, LDH, AST, and ALT were similar in both the control and PRP groups. However, 24-h following exercise a significant increase in these parameters was observed in both groups between 1 and 4 days during the recovery period. Interestingly, PRP administration decreased plasma iron levels compared to the control on the second day post-exercise. Plasma IBC increased in PRP group from Days 2 to 4 post-exercise compared to the control group whilst PRP administration had no effect on plasma ferritin, CK, AST, ALT, or LDH. CONCLUSION: Acute exhaustive exercise increased muscle damage markers, including plasma iron, IBC, and ferritin levels, indicating muscle damage induced by exercise. PRP administration improves inflammation by reversing the increase in the iron levels post-exercise without displaying any myotoxicity and may have a role to play in the recovery of exercise-induced muscle damage.

Intertrochanteric femur fractures in the elderly treated with either proximal femur nailing or hemiarthroplasty: A prospective randomised clinical study.

INTRODUCTION: The purpose of this prospective randomised study is to compare in the elderly the functional results of intertrochanteric femur fractures treated either with closed reduction and internal fixation with proximal femoral nailing or cemented hemiarthroplasty. MATERIALS AND METHODS: The study included patients above the age of 75 who were diagnosed with intertrochanteric femur fracture and admitted to the Department of Orthopaedics and Traumatology, Ege University Hospital between October 2006 and December 2012. After informed consent was obtained from the patients, they were randomised via sealed opaque envelops into two groups. Patients in Group 1 were internally fixated utilizing proximal femoral nail, whilst the patients in Group 2 were treated with a cemented hemiarthroplasty. Complications were recorded and functional results were evaluated using the Harris Hip score. The mean time of follow up was 31.72 months (min. 18-max. 47, std. dev. ±10.68). RESULTS: A total of 54 patients were included in the study. 21 of them (38.9%) received a proximal femoral nail whilst 33 (61.1%) were treated with hemiarthroplasty. Average age of the patients was 82.24 (min. 75-max. 97). Average age in Group 1 was 79.57 (min. 75-max. 91), whilst it was 83.94 in Group 2 (min. 75-max. 97). Harris Hip score analysis revealed that the difference between the patients treated with hemiarthroplasty and proximal femoral nailing was statistically significant in favour of the hemiarthroplasty group within the first 3 months. However, this difference diminished at the 6th month time point, and even reversed as of the 12th month postoperatively. DISCUSSION AND CONCLUSIONS: Although cases with hemiarthroplasty achieved a better level of activity in the beginning, cases with proximal femoral nailing reached a comparable level of activity within a short period of time, faster than those treated with hemiarthroplasty, displaying a better level of activity in the end.

Should full threaded compression screws be used in adult femoral neck fractures?

INTRODUCTION: Operative treatment consisting of fracture reduction and fixation, or arthroplasty to permit early patient mobilization, continues to be the treatment of choice for most femoral neck fractures. Options for internal fixation have included a variety of implants; however most recent reports and textbooks cite parallel multiple cancellous screws as the surgical technique of choice. METHODS: The study was prospective, randomized and IRB approved. Inclusion criteria included skeletal maturity, closed femoral neck fracture without concomitant fractures or injuries with complete charts and adequate radiographs obtained from the initial injury till the last follow-up. Forty-four patients were enrolled in this study during one-year period at two university centers. 22 were randomized to be treated with full threaded, cannulated compression screws (Acutrak 6/7, ACUMED) (Group 1) and the other 22 with 16mm partial threaded, 6.5mm or 7.3mm cannulated screws (SYNTHES) (Group 2). Three or four screws were used in both groups according to fracture type and surgeon's preference. Data evaluated included surgical time, fluoroscopy time, fracture type, radiological outcome, complications and functional status using the Harris Hip Score. RESULTS: Both groups were comparable in terms of age and gender. There was not a significant difference in terms of surgical time, follow-up period, fracture type, or fluoroscopy time. There were eight complications in Group 1 and two in Group 2 (P=0.049) Time to union was significantly longer in Group 1 (P=0.001). However, Hip Scores were not significantly different in both groups (P=0.20). CONCLUSION: When compared with full threaded compression screws, partial-threaded cannulated screws provides a shorter union time and less complication rate while providing equivalent functional results in adult femoral neck fractures.

Which implant is better for treating reverse obliquity fractures of the proximal femur: a standard or long nail?

BACKGROUND: Reverse obliquity fractures of the proximal femur have biomechanical characteristics distinct from other intertrochanteric fractures and high implant failure rate when treated with sliding hip screws. Intramedullary hip nailing for these fractures reportedly has less potential for cut-out of the lag screw because of their loadbearing capacity when compared with extramedullary implants. However, it is unclear whether nail length influences healing. QUESTIONS/PURPOSES: We compared standard and long types of intramedullary hip nails in terms of (1) reoperation (fixation failure), (2) 1-year mortality rate, (3) function and mobility, and (4) union rate. METHODS: We conducted a pilot prospective randomized controlled trial comparing standard versus long (≥ 34 cm) intramedullary hip nails for reverse obliquity fractures of the proximal femur from January 2009 to December 2009. There were 15 patients with standard nails and 18 with long nails. Mean age was 79 years (range, 67-95 years). We determined 1-year mortality rates, reoperation rates, Parker-Palmer mobility and Harris hip scores, and radiographic findings (fracture union, blade cut-out, tip-apex distance, implant failure). Minimum followup was 12 months (mean, 14 months; range, 12-20 months). RESULTS: We found no difference in reoperation rates between groups. Two patients (both from the long-nail group) underwent revision surgery because of implant failure in one and deep infection in the other. There was no difference between the standard- and long-nail groups in mortality rate (17% versus 18%), Parker-Palmer mobility score (five versus six), Harris hip score (74 versus 79), union rate (100% in both groups), blade cut-out (zero versus one), and tip-apex distance (22 versus 24 mm). CONCLUSIONS: Our preliminary data suggest reverse obliquity fractures of the trochanteric region of the femur can be treated with either standard or long intramedullary nails.

Avulsion fractures of tibial tuberosity in adolescents. Treatment with closed reduction and percutaneous screwing, using MRI to identify combined intraarticular lesions.

Avulsion fracture of the tibial tuberosity is an uncommon lesion generally seen in adolescents. Intra-articular lesions combined with a tibial tuberosity fracture reported in the literature are; 3 patellar tendon ruptures, 2 anterior cruciate ligament tears, 2 medial collateral ligament tears, 2 medial meniscus tears, one arcuate ligament tear, and one lateral meniscus tear. In our study, both cases sustained an avulsion fracture of the tibial tuberosity. Preoperative MRI in one case revealed posterior cruciate ligament rupture. Under the image intensifier, we treated both patients by closed reduction and percutaneous screwing with 2 cancellous screws. Radiographic assessment showed complete healing of the avulsion fractures in both cases. Both of our patients gained previous levels of daily and sporting activity prior to the injury, and were completely asymptomatic. Our objective in reporting this case study is to point to the fact that there is no previous reporting of the avulsion fracture of the tibial tuberosity accompanied by posterior cruciate ligament rupture in the literature and to evaluate the findings of the minimal invasive treatment method we applied to both cases.

Absolute compartment pressure versus differential pressure for the diagnosis of compartment syndrome in tibial fractures.

We studied 39 patients with 42 diaphyseal tibial fractures in whom we suspected a high risk for the development of a compartment syndrome. We measured the anterior absolute compartment pressure (ACP) every 12 h for 72 h and also recorded the differential pressure (DeltaP=diastolic blood pressure-ACP). Fasciotomy of the extremity was only performed when the differential pressure was less than 30 mmHg for more than 30 min. The highest values of the ACP were recorded between 24 h and 36 h after admission. Three fractures had a differential pressure less than 30 mmHg and all were treated by fasciotomy. In three fractures the ACP was equal to or higher than 50 mmHg, of which two had a differential pressure less than 30 mmHg. The patients were followed up for a mean of 36 months (29-45). All fractures healed, and none of our patients showed any sequelae of compartment syndrome at their last review.

[Monitoring of uncooperative, polytraumatized patients with tibial shaft fractures for acute compartment syndrome]. / Tibia cisim kirikli, kooperasyon kurulamayan, politravmali hastalarin kompartman sendromu açisindan izlemi.

BACKGROUND: The results of intracompartmental pressure monitoring were assessed in uncooperative, polytraumatized patients with tibial shaft fractures. METHODS: The study included 29 tibial fractures of 26 polytraumatized patients (9 females, 17 males; mean age 36 years; range 15 to 75 years) admitted to the intensive care unit. The fractures were on the right side in eight patients, on the left in 15 patients. Three patients had bilateral involvement. All the patients were unconscious. Following trauma, absolute compartment pressures and ΔP (diastolic blood pressure - absolute compartment pressure) were monitored at 12-hour intervals for 72 hours via the intracompartmental pressure monitoring system. Patients whose ΔP values were 30 mmHg or below underwent fasciotomy. The mean follow-up period was 21.2 months (range 18 to 25 months). RESULTS: The overall mean absolute compartment pressure was 30.25 mmHg, and the mean ΔP was 48.47 mmHg at the end of 72 hours. Fasciotomy was performed in two patients (7%) in whom a diagnosis of acute compartment syndrome was made depending on ΔP values less than 30 mmHg. None of the patients had complications associated with acute compartment syndrome. Union was achieved in all the patients without an additional intervention. The mean time to union was 5.21 months (range 3 to 9 months). CONCLUSION: Intracompartmental pressure monitoring should be considered for an early diagnosis of acute compartment syndrome in uncooperative, polytraumatized patients with tibial shaft fractures.

[Long-term results of elastic intramedullary nailing in pediatric femoral shaft fractures]. / Cocuk femur cisim kiriklardinda elastik intramedüller Civilemenin geç dönem sonuçlari.

BACKGROUND: In our retrospective study, we evaluated pediatric femoral shaft fractures sustained by children of five to fifteen years of age, all of whom were treated with elastic intramedullary nailing. METHODS: Between 1990 and 2000, 32 femoral fractures of 30 children, 14 (47%) polytraumatized, with an average age of 9.9 (6-14), were treated with elastic intramedullary nailing. RESULTS: Average follow-up was 105.3 (25-145) months. Three cases (9.3%) were re-operated due to developed angulations related to weight bearing in the early postoperative period. In three (9,3%) of our cases we diagnosed more than five degrees valgus deformity, in one (3.1%) anterior angulation and in 1 (3.1%) internal rotation. The average of absolute value of length discrepancies was determined as 9 mm (-15mm - +15mm). CONCLUSION: Elastic intramedullary fixation is a recommended method, especially for polytraumatized patients, because of facilitates of patient care, recovers social activity quickly, and causes minimal soft tissue damage. However angular or rotational deformations are also possible. Selection criteria and follow up period is important and treatment of the complications must be on time.

[Risk of compartment syndrome in open and closed tibial fractures]. / ACIK VE KAPALI TIBIA KIRIKLARINDA KOMPARTMAN SENDROMU GELISME RISKI.

BACKGROUND: In orthopaedic traumatology; acute compartment syndrome is a common complication associated with tibial fractures. In our study, we investigate differences, if any, between open and closed tibialfractures in terms oftheir risk of compartment syndrome. METHODS: Fourty-two tibial fractures of 39 patients, 29 (69%) closed and 13 (31%) open, having the risk of acute compartment syndrome according to the clinical examination, were monitored following traumas during which their DP (DP= Diastolic blood pressure -Absolute compartment pressure) and absolute compartment pressures were measured via intracompartmental pressure measuring equipment. RESULTS: Average absolute compartment pressure was found to be 31.25 mmHg in open and 29,32 mmHg in closed fractures (p=O,484) whereas average DP was measured to be 47,46 mmHg in open and 49,66 mmHg in closedfractures (p=O,415). According to student's test, the difference between the two groups was not significant. We found the incidence of acute compartment syndrome as 7, 7% in open fractures, 6.9% in closed and 7, 1 % in overall tibial fractures andfasciotomy was carried out in those cases. CONCLUTION: Statistically not significant difference between the pressure levels,found in open and closed tibialfractures, showed that open type oftibialfractures holds the risk of compartment syndrome as much as the closed one.