Analysis of the factors affecting pain level during K-wire removal among pediatric elbow fractures.

Our aim was, to analyze the reasons for possible increased pain during the removal of the Kirschner wires from the elbows of children. From February 2021 to December 2021, 573 patients with elbow fractures were treated. In total, 150 patients were analyzed prospectively. No action was taken to reduce pain during the removal of Kirschner wires. The pain status of the patients was evaluated according to the Wong-Baker FACES Pain Rating scoring system (WBAS), the Numeric Rating Scale (NRS) for the pain system and the pulse and oxygen saturation measured by the pulse oximeter on the finger. Measurements were performed before, during, immediately after and 30 min after the procedure. There were 119 patients with a diagnosis of supracondylar humerus fracture and 31 patients with a diagnosis of lateral condyle fracture. The mean age of treated patients was 7.1 years (1-15 years). Of the patients, 93 were boys and 57 were girls. In the measurements made according to the sex difference, it was determined that there was a statistically significant increase in the WBAS scores measured both before the procedure ( P = 0.032) and during the removal ( P = 0.017), and also in the pulse measurements taken 30 min after the removal in girls ( P = 0.034). A statistically significant difference was found in both the WBAS score during removal ( P = 0.025) and the NRS scores 30 min later ( P = 0.048) in the procedures performed on the right elbow. We found a statistically significant increase in the pain parameters we evaluated in girls, right extremity fractures, the group over 8 years old and when both parents were with the child during the K-wire removal procedure. In light of these findings, physicians should consider the above-mentioned conditions before starting the procedure to ensure a less painful and positive experience.

Comparison of the Reliability of Three Scoring Systems Used to Decide Whether to Apply Cement in Hip Arthroplasty Among Fracture Patients and the Effect of Surgical Experience: The Spotorno, Dorr, and Canal Flare Indices.

BACKGROUND: No consensus has been reached regarding the best index to decide whether to use cement during hip replacement surgery. Therefore, this study compared the reliability of three frequently used scoring systems. The secondary purpose was to evaluate the effect of surgical experience on the decision to use cement. METHODS: Anteroposterior radiographs of 60 hips were assessed by four orthopedic surgeons and four orthopedic residents. The observers were asked to make measurements using the Spotorno criteria, the Dorr index, and the canal flare index, and to decide whether to use a cemented or cementless femoral stem. The same X-rays were sent to all participants, in a different order, 4 weeks later, for a second evaluation. The SPSS software (version 24.0) was used for the statistical analysis. Intraobserver agreement was determined for all observers via the intraclass correlation coefficient (ICC), and interobserver reliability was calculated using the weighted kappa (κ) statistic. RESULTS: The average age of the patients were 73.1 ± 12.1 years. Thirty-three (55%) patients were female and thirty-two (53.3%) had fractures on the right side. Intraobserver agreement was "excellent" for all participants according to the Spotorno criteria. The canal flare index had the lowest intra-observer agreement. The highest interobserver agreement was found using the Spotorno criteria. CONCLUSION: The intra- and interobserver reliabilities of the Spotorno criteria were higher than those of the Dorr index and the canal flare index. The Spotorno criteria was more useful for deciding between cemented and un-cemented hip arthroplasty.

Use of the forgotten joint score (FJS)-12 to evaluate knee awareness after isolated anterior cruciate ligament reconstruction with and without meniscus repair or partial meniscectomy.

PURPOSE: The aim of this study was to compare knee awareness, based on the FJS-12 score, among three patient groups: Anterior cruciate ligament reconstruction (ACLR), ACLR + meniscus repair and ACLR + partial meniscectomy. The relationship between FJS-12 scores and scores on other instruments (Lysholm Knee Scoring Scale, Tegner Activity Level Scale, KOOS and WOMAC) was also evaluated. METHODS: Forty-three patients were divided into group A (isolated ACLR) group B (ACLR + meniscectomy) and group C (ACLR + meniscus repair). Graft thickness, femoral tunnel width, tibial tunnel width, tibial screw thickness and follow-up time were evaluated in all three groups. The subjective knee scores (KOOS, WOMAC, Lysholm Knee Scoring Scale, Tegner Activity Level Scale and FJS-12) of the groups were then compared. RESULTS: FJS-12 scores of 43 patients were evaluated. The mean age was 26.1 ± 6.5 years (range: 18-40 years). Group A: 23; group B: 9 and group C include 11 patients. The mean FJS-12 score of group B (median: 100 [range: 98-100]) was higher than that the others. Spearman's rho test showed that the FJS-12 is highly compatible with the other scores. CONCLUSION: According to this study, FJS-12 and the other scoring systems showed that ACLR with partial meniscectomy is the most effective surgical method to restore normal sensation in the knee.

Posterior Tibial Slope and a New Morphometric Method With Multiplanar Reconstruction Technique in a Turkish Sample.

AIM: The posterior tibial slope (PTS) is important in planning many orthopedic procedures. The aim of the study is to outline a PTS measurement method using multiplanar reconstruction (MPR) in knee computed tomography (CT) images. METHODS: MPR reconstruction was performed on pre-captured CT angio images of 124 patients. A standard tibial axis was created. Then, using reference points, the PTS was measured separately for the medial PTS (MPTS) and lateral PTS (LPTS). To identify an intra- and interobserver error, the technical error of measurement (TEM), relative TEM (rTEM), and coefficient of reliability (R) of the measurement were analyzed. RESULTS: The study enrolled 124 patients (88 males, 36 females) from 18 to 92 years old. The average MPTS 8.63 ± 2.7° and LPTS 7.77 ± 3.1° were significantly different (p < 0.05). However, there was no difference between the sexes (p = 0.52 for MPTS; p = 0.9 for LPTS). The R for intraobserver reliability was 0.942 for the MPTS and 0.943 for the LPTS, and that for interobserver reliability was 0.815 and 0.806, respectively. CONCLUSIONS: PTS measurement from CT images appears advantageous as it eliminates measurement limitations due to tibial rotation and has high intra- and interobserver consistency.

How Long Do Octogenarians Benefit From Knee Arthroplasty?

Introduction Elderly patients are more prone to surgical risk regardless of the procedure. The overall mortality rate is expected to be high in this population. The aim of this study was to evaluate the survival rates of octogenarians who underwent knee arthroplasty procedures. Methods Sixty-two knee arthroplasties were performed on 52 patients who were >80 years of age at the time of the operation between November 1996 and May 2014. The preoperative American Society of Anesthesiologists (ASA) classes were available for 45 procedures. The database of the Civil Registry Service was used to assess whether the patients were alive at the time of the study. If they were deceased, their dates of death were recorded. The five-, 10-, and 15-year survival rates of patients were determined. Results Thirty patients (57.69%) were alive and 22 (42.31%) were deceased at the time of analysis. Based on the 62 procedures, the mean age of the patients at the time of the operation was 82.56 ± 2.18 years. The mean time span between the operation and death of patients who passed away was 6.4 ± 4.66 years. The mean age of the patients who were alive at the time of the study was 86.63 ± 3.60 years. The mean time that had passed since the operation was 4.41 ± 2.9 years for living patients. Only one patient died during the first 90 days postoperatively. The one-year mortality rate was 4.84% (three patients). A Kaplan-Meier survival analysis revealed that the mean survival time of the patients was 6.4 years, and the median survival time was 5.6 years. The five-year survival rate was 59%, the 10-year rate was 19%, and the 15-year rate was 7%. Conclusion Octogenarians benefitted from knee replacement longer than expected. Early mortality risks can be avoided with proper patient selection.

Analysis of Factors Affecting Return to Work After Surgical Treatment in Patients with AO Type C Distal Humerus Fractures.

BACKGROUND: The purpose of this study is to evaluate the functional results of distal humerus fractures which were treated by open reduction and fixation with pre-contoured angular stable plates in young patients, and investigate whether the patients could return to their pre-injury work and patients' financial conditions while they were not working. MATERIALS AND METHODS: The data of 48 patients, ages between 18 and 55 years, working in a job and having AO/OTA type C distal humerus fracture were retrospectively evaluated. Mayo Elbow Performance Score (MEPS) was used to determine functional results. Postoperative radiographs were evaluated to determine the rate of union, degenerative changes, malunion and heterotopic ossification. Financial outcome form was constituted by the authors and the patients asked whether she/he could return to their pre-injury works after treatment finished and the financial status of the patients during the treatment and after the treatment. RESULTS: The mean flexion-extension arc was 114° ± 12°(range 85°-135°) and the mean MEPS score was 85 ± 11(range 65-100). The average time to return to work was 6.5 ± 2.4 months (3-12 months). AO type C2 and C3 fractures and heterotopic ossification negatively affected the functional results and also adversely affected the patients' return to their pre-injury works. 38 (79%) patients returned to pre-injury work and 29 (76%) of them started to work at the same position before the fracture occured. Nine of 38 patients (24%) had to change their positions. Among the 48 patients, 10 patients (21%) could not return to the same work, 7 of them found light duty and 3 of them had not been to work. CONCLUSION: Although the functional results of surgical treatment of intra-articular distal humerus fractures are good, at the end of the treatment, especially heavy workers may have difficulties in returning to their former works.

Forensic age estimation via magnetic resonance imaging of knee in the Turkish population: use of T1-TSE sequence.

The evaluation of epiphyseal areas by magnetic resonance imaging (MRI) for forensic age estimation is an important supportive diagnostic method to prevent repeated radiation exposure without a valid medical reason. There are still not enough individuals being analyzed with MRI for age estimation. The aim of this study was to investigate the utility of T1-weighted turbo spin echo (T1-TSE) MRI sequences in determining the degree of ossification of the distal femoral and proximal tibial epiphyses in a Turkish population. In this study, images from 649 patients (335 males and 314 females) aged 10-30 years were retrospectively evaluated with sagittal T1-weighted turbo spin echo (T1-TSE) MRI sequences of the knee. Proximal tibial and distal femoral epiphysis were scored by two different observers twice using the combined staging system described by Schmeling and Kellinghaus. Spearman's rank correlation analysis indicated a significant positive relationship between age and ossification stages of the distal femoral and proximal tibial epiphyses (p < 0.001). The intra- and inter-observer reliabilities in evaluating the femur and tibia were separately determined and gave promising results and Cohen's kappa statistics ranged from κ = 0.886 and κ = 0.961. The minimal ages of patients with stage 4 ossification were 15.1 years for females and 15.8 years for males for the distal tibial epiphysis and 15.4 years for females and 17 years for males for the distal femoral epiphysis. This study show that (T1-TSE) MRI and the applicability and Schmeling and Kellinghaus staging method of the knee can be performed for living 14- to 17-year-old individuals in need of a supportive noninvasive method for estimating forensic age.

Can titanium elastic nail be safely used for paediatric subtrochanteric femur fractures?

In this study, we aimed to show that subtrochanteric femur fractures, an uncommon type of fracture in the paediatric age group, can be treated with titanium elastic nailing (TEN). We reviewed the patients treated with TEN in the paediatric age group with subtrochanteric femur fractures who had been treated at the Orthopaedics and Traumatology Clinic of Izmir Tepecik Research and Training Hospital between January 2011 and December 2016 retrospectively. All fractures were fixed by retrograde nailing with supracondylar entry following reduction. Patients' demographics as well as data such as fracture type, fracture level, time of operation, reduction type, time to union, shortness, additional fixation, duration of additional fixation, Flynn scores and reduction loss were evaluated. The 20 patients included in our study were followed up for at least 1 year, had an age range of 54-173 months (mean, 104 ± 31.82 months) and were operated within 2-11 days after fracture. All patients had fracture union and only three patients had union with an angulation of less than 5°. None of the patients had limb length inequality. Fourteen patients underwent reoperation, all of these were routine operations for implant removal and no patients required reoperation for complications. We think that paediatric subtrochanteric femur fractures can be treated by TEN fixation using the proper technique, with a limited invasive intervention.

Evaluation of Clinical and Radiological Results of Humeral Diaphyseal Fractures with Treated Sarmiento Brace.

Aim In our study, we aimed to evaluate the duration and rate of the union of adult humerus diaphysis fractures treated with a functional brace. Methods Forty-six adult patients admitted to our hospital with humeral diaphyseal fracture between January 2010 and April 2014 and treated with a functional brace were evaluated retrospectively. The demographic data, fracture type, level of fracture, and presence of bone union of the patients were evaluated from clinic records. The Disabilities of the Arm, Shoulder and Hand (Quick-DASH) questionnaire score of the patients was registered for patients and analyzed, and its correlation with parameters such as patient age and fracture bone union time was evaluated. Results It was observed that of the patients with the mean age of 45.5 years, six (13.6%) had non-union and five had delayed bone union (10.86%). Three (6.5%) patients had radial nerve injury, and all recovered without sequelae. Out of the patients with the bone union, 12 (30%) had an angulation above give degrees, and 3 (7.5%) had radiological shortness. The mean Quick-DASH score was 6.7, and there was no statistically significant correlation with parameters such as fracture type, level, angulation, radiological shortness and radial nerve involvement (p>0.05). Conclusions A functional brace is a good treatment choice with low complication rates and has satisfactory bone union rates in humerus diaphyseal fractures.

Viewing arthrography images affects treatment preferences for Legg-Calvé-Perthes disease among medical professionals.

OBJECTIVES: We explored how experience of arthrography affects treatment preferences for Legg-Calvé-Perthes disease (LCPD) patients. We also examined changes in surgical procedure preferences after examining arthrography images. In addition, we analysed the effect of experience with arthrography on treatment and surgical modality preferences. METHODS: A case-based questionnaire was completed by 26 participants. Information on age, symptoms, hip range of motion (ROM), and extremity length differences were provided for eight LCPD cases. Based on these data and roentgenography images of the cases, the respondents were questioned regarding diagnostic, treatment, and surgical preferences. A slide was shown of arthrography images of each case and the same questions were asked to determine any changes in treatment preferences. The participants were divided into arthrography-experienced (Group 1, n = 16) and -inexperienced (Group 2, n = 10) groups to determine differences in treatment preferences in association with experience. RESULTS: After the participants had examined the arthrography images, a significant decrease in the number of additional examination requests was observed (p < 0.001). A significant group difference was also found in the rate of change of preference in diagnostic modality (p < 0.001).After arthrography images were examined, the tendency towards a preference for surgery increased in all participants. However, no significant difference between the experience groups was observed (p = 0.193). In addition, after arthrography images were examined, there was an increased tendency towards a preference for femoral valgisation and Salter osteotomy among participants who chose surgical treatments (p = 0.408). The treatment preferences difference between the two experience groups were not significant, and nor was the preference regarding surgical procedures (p = 0.999). CONCLUSIONS: Previous studies have shown that arthrography is useful for planning treatment and informing decisions regarding surgical modality for LCPD. However, no study has explored changes in treatment preferences after viewing arthrography images. This study explored such changes in choices regarding the diagnostic method and treatment modality. Our study showed that experience with arthrography decreased the preference for additional diagnostic tests (p < 0.001). Experience of arthrography increased the preference for surgery, though not significantly (p = 0.193).

Pediatric Forearm Refracture with Intramedullary Nail Bending In Situ: Options for Treatment.

In this study, we present the case of a nine-year-old male patient who had initially presented to the emergency department with a right both-bone forearm fracture. He was treated with closed reduction and long-arm casting. The cast was applied for six weeks and then replaced with a short-arm cast for two weeks. The patient returned with a both-bone forearm refracture one and a half months after the removal of the cast. Surgical treatment was initiated and an intramedullary nail fixation was applied. The patient sustained a new trauma five months postoperatively. The condition was diagnosed to be a refracture of the both-bone forearm with an intramedullary nail in situ. Closed reduction was performed, but an acceptable level of reduction was not achieved. Subsequently, intramedullary nails were replaced with new nails. At the one year follow-up, the patient was observed to have a full range of motion and reported no pain or muscle weakness.

Treatment of pelvic Ewing's sarcoma: Pros and cons of chemotherapy plus definitive radiotherapy versus surgery.

OBJECTIVE: The aim of this study was to compare the results of chemotherapy or combined chemotherapy-radiation therapy with surgical intervention following neodjuvant therapy in pelvic Ewing's sarcoma patients. METHODS: The study population consisted of 39 patients with pelvic Ewing's sarcoma treated in our clinic between 1994 and 2014. Of these patients, 28 patients (11 boys and 17 girls; mean age: 19.57±6.8 years) were treated with chemotherapy and radiation therapy and the remaining 11 patients (9 boys and 2 girls; mean age: 18.64±8.1 years) patients underwent surgical intervention after neoadjuvant chemotherapy or chemotherapy plus radiation therapy. Internal hemipelvectomy was performed in 10 patients, and external hemipelvectomy was performed in one patient. Survival rates were compared between the surgical and non-surgical treatment groups. Predictive factors, such as treatment protocol (surgery, neoadjuvant chemotherapy, definitive radiotherapy), mass localisation, mass size, presence of metastasis at the time of diagnosis, and presence of late metastases were compared between the groups. The effects of each variable on survival were also examined. RESULTS: The overall 3- and 5-year survival rates of the 28 non-surgical patients were 41.4% and 26.1%, respectively, while those of the surgical patients were 53% and 35.4%, respectively (p=0.777). Large mass size, presence of metastasis at the time of diagnosis, and presence of late metastases were significantly associated with lower survival rates. CONCLUSION: The survival rates of the patients who underwent surgery were higher than those of non-surgical patients, although the difference was not statistically significant. Definitive radiation and chemotherapy would be preferable in selected cases, such as patients with sacral localisation, without surgical intervention. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

Posterior tibial slope of the knee measured on X-rays in a Turkish population.

PURPOSE: Posterior tibial inclination of the knee joint should be considered during anterior cruciate ligament reconstruction and total knee replacement surgery. This inclination is called the posterior tibial slope (PTS) angle. The PTS differs among populations and the aim of this study was to determine the mean PTS in a Turkish population. METHODS: PTS was measured retrospectively on lateral knee X-rays (n = 1024). The angle between the line connecting the anterior and posterior points of the lateral tibial plateau and the tibial longitudinal axis was taken as the PTS angle. Intra- and inter-observer agreement regarding the measurements on 20 X-rays were checked. RESULTS: The mean PTS angle for the entire cohort was 8.36 ± 3.3° (range: 2.1-18.7°); it was 8.57 ± 3.4° (range: 2.3-17.4°) in men and 8.16 ± 3.2° (range: 2.1-18.7°) in women. Although no significant correlation was detected between PTS and age, PTS was higher in men than in women. CONCLUSION: The increasing number of total knee replacement surgeries has increased the need for studies on implant mismatch. In this study, reference PTS values were determined for a Turkish population. It may be beneficial to use patient-specific implants in some cases.

Estimating forensic age via magnetic resonance imaging of the distal radial epiphysis.

Magnetic resonance imaging is currently being studied extensively, but it is still far from being the frequently recommended radiological method for age estimation. In this study, we used magnetic resonance imaging (MRI) of distal radius ossification to obtain data for age estimation. Wrist MRI scans from 338 individuals, aged 10-29 years, were examined retrospectively using the staging system of Schmidt et al. and the extension of the stages as described by Timme et al. The results revealed that the minimum ages for stage 4a ossification were 16.0 years in women and 17.7 years in men, whereas those for stage 4b ossification were 16.6 and 18.2 years in women and men, respectively. Stage 5 was not detected in any patient. These results were comparable with those of a previous study using the same methodology with distal radial epiphysis ossification. Our finding regarding stage 4b ossification may provide valuable information on legally important age thresholds relevant to the use of MRI in evaluating the distal radial epiphysis in males. Further research needs to be conducted with large series in different populations to evaluate the triple banding at the distal radial epiphysis.

Is open reduction necessary for pediatric T-condylar fractures of the humerus?

The aim of this study was to investigate the outcomes of closed reduction and percutaneous pinning (Kirschner wire fixation) as a less invasive method for the treatment of pediatric T-condylar fractures of the humerus compared with open reduction and pinning. Among pediatric patients who were diagnosed with T-condylar fractures of the humerus between 2010 and 2017, those who underwent closed reduction and percutaneous pinning were retrospectively evaluated. The surgical technique used was to restore joint alignment through closed reduction and then to insert a pin parallel to the joint surface to stabilize the intercondylar fracture. Then, the supracondylar fracture was fixed with crossed pins. At 1-year follow-up, rotation, angulation, and joint range of motion were evaluated. Patient satisfaction was assessed subjectively using the visual analogue scale. Early and late postoperative Baumann angles were measured. All patients were male, and the mean age was 10.8 ± 4.6 years. The mean follow-up duration was 16.5 ± 7.2 months, and the mean union duration was 7.4 ± 2.3 weeks. None of the patients had any rotational deformities, but two had 5° of varus, one had 5° of valgus, two had a flexion contracture of 10°, and one had a flexion contracture of 40°. The only complication observed was a pin-tract infection, which developed in one patient. The mean visual analogue scale score was 9.25 ± 1. In pediatric patients with T-condylar humerus fractures, closed reduction and percutaneous pinning may be a good alternative to open reduction and pinning, because it is less invasive and does not cause additional complications.

Applicability of T1-weighted MRI in the assessment of forensic age based on the epiphyseal closure of the humeral head.

This work investigates the value of magnetic resonance imaging analysis of proximal epiphyseal fusion in research examining the growth and development of the humerus and its potential utility in establishing forensic age estimation. In this study, 428 proximal humeral epiphyses (patient age, 12-30 years) were evaluated with T1-weighted turbo spin echo (T1 TSE) sequences in coronal oblique orientation on shoulder MRI images. A scoring system was created following a combination of the Schmeling and Kellinghaus methods. Spearman's rank correlation analysis revealed a significant positive relationship between age and ossification stage of the proximal humeral epiphysis (all subjects: rho = 0.664, p < 0.001; males: 0.631, p < 0.001; females: rho = 0.651, p < 0.001). The intra- and inter-observer reliability assessed using Cohen's kappa statistic was κ = 0.898 and κ = 0.828, respectively. The earliest age of epiphysis closure was 17 years for females and 18 years for males. MRI of the proximal humeral epiphysis can be considered advantageous for forensic age estimation of living individuals in a variety of situations, ranging from monitoring public health to estimating the age of illegal immigrants/asylum seekers, minors engaged in criminal activities, and illegal participants in competitive sports, without the danger of radiation exposure.

Forensic age diagnostics by magnetic resonance imaging of the proximal humeral epiphysis.

The most commonly used radiological method for age estimation of living individuals is X-ray. Computed tomography is not commonly used due to high radiation exposure, which raises ethical concerns. This problem can be solved with the use of magnetic resonance imaging (MRI), which avoids the use of ionizing radiation. The purpose of the present study was to evaluate the utility of MRI analysis of the proximal humeral epiphyses for forensic age estimations of living individuals. In this study, 395 left proximal humeral epiphyses (patient age 12-30 years) were evaluated with fast-spin-echo proton density-weighted image (FSE PD) sequences in a coronal oblique orientation on shoulder MRI images. A five-stage scoring system was used following the method of Dedouit et al. The intra- and interobserver reliabilities assessed using Cohen's kappa statistic were κ = 0.818 and κ = 0.798, respectively. According to this study, stage five first appeared at 20 and 21 years of age in males and females, respectively. These results are not directly comparable to any other published study due to the lack of MRI data on proximal humeral head development. These findings may provide valuable information for legally important age thresholds using shoulder MRI. The current study demonstrates that MRI of the proximal humerus can support forensic age estimation. Further research is needed to establish a standardized protocol that can be applied worldwide.

The fate of fibular osteotomies performed during high tibial osteotomy.

INTRODUCTION: High tibial osteotomy (HTO) is an important treatment alternative in isolated single compartment knee osteoarthritis. To achieve adequate mechanical axis corrections in the lower extremity fibula is also osteotomized concomitantly. The aim of this study was to compare the union rates of proximal and diaphyseal fibular osteotomies accompanying high tibial osteotomies. METHOD: Sixty-seven knees of sixty-three patients who had undergone HTO were retrospectively evaluated. The patients were grouped according to the level of the fibular osteotomy (FO). In group I, the level of FO was proximal, and in group II, it was at the level of junction of middle and distal third of diaphysis. The union rates of FOs at two different levels were compared. The influence of the presence of displacement at the osteotomy site and apposition between bone ends on union was also evaluated. RESULTS: Fifty-nine of sixty-seven FOs (88.06 %) were united. The union rate of proximal FOs was significantly greater than diaphyseal osteotomies (p < 0.0001); 97.9 % of proximal FOs were united, whereas this ratio was 65 % for the diaphyseal FOs. The presence of displacement at the FO and apposition between bone ends significantly influenced the bony union rate (p values 0.035 and <0.0001, respectively). CONCLUSION: Union rates and nonunion characteristics of FO might differ according to its level, apposition of bone ends, and contact area. The fate of FO might also affect the union of HTO.