Reliability of Real-Time Sonoelastography in the Diagnosis of Supraspinatus Tendinopathy.

ABSTRACT: The practicality of real-time sonoelastography in the diagnosis of tendinopathy is being discussed since the beginning of its use in musculoskeletal system. The aims of this study were to compare the elasticity of pathologic supraspinatus tendon with the uninvolved side by sonoelastography and to determine the relationship between the sonoelastographic findings and magnetic resonance imaging (MRI) grade of the tendinosis. Eighty-2 patients (50 males, 32 females, mean ± SD age = 53.61 ± 16.15 years, range = 20-84 years) with unilateral supraspinatus tendinosis were included in this study. Three grades of tendinosis were identified in MRI (grade 1: mild, grade 2: moderate, and grade 3: severe). The strain ratio (SR) of the tendinosis area to the healthy normal area of the same tendon tissue and SR of the tendinosis area to ipsilateral subcutaneous fat tissue were evaluated with sonoelastography. The SRs of the tendinosis areas were also compared with the control (contralateral) side tendon tissue and subcutaneous fat tissue of the same patients. Between-groups comparisons were also done according to the MRI grading. Statistical analysis was done using paired t test (P < 0.005 was considered statistically significant). There was a statistically significant difference in the comparison of the SRs of the tendinosis areas to subcutaneous fat tissues on ipsilateral shoulders (TA/SFT) and the healthy supraspinatus tendon area (TA/ST) of the same shoulder. There was also statistically significant difference when compared with the control side measurements (P < 0.01). In patients who have grade 1 and grade 3 tendinosis on MRI, there was statistically significant difference between elastrographic evaluation of affected and unaffected sides. Real-time sonoelastography is a reliable diagnostic method in patients with rotator cuff tendinosis and shall be kept in mind as a noninvasive, inexpensive, and practical diagnostic test in suitable cases.

Tourniquet pressure settings based on limb occlusion pressure determination or arterial occlusion pressure estimation in total knee arthroplasty? A prospective, randomized, double blind trial.

OBJECTIVE: The aim of this study was to compare the limb occlusion pressure (LOP) determination and arterial occlusion pressure (AOP) estimation methods for tourniquet pressure setting in adult patients undergoing knee arthroplasty under combined spinal-epidural anesthesia. METHODS: Ninety-three patients were randomized into two groups. Pneumatic tourniquet inflation pressures were adjusted based either on LOP determination or AOP estimation in Group 1 (46 patients, 38 female and 8 male; mean age: 67.71 ± 9.17) and Group 2 (47 patients, 40 female and 7 male; mean age: 70.31 ± 8.27), respectively. Initial and maximal systolic blood pressures, LOP/AOP levels, required time to estimate AOP/determinate LOP and set the cuff pressure, initial and maximal tourniquet pressures and tourniquet time were recorded. The effectiveness of the tourniquet was assessed by the orthopedic surgeons using a Likert scale. RESULTS: Initial and maximal systolic blood pressures, determined LOP, estimated AOP, duration of tourniquet and the performance of the tourniquet were not different between groups. However, the initial (182.44 ± 14.59 mm Hg vs. 200.69 ± 15.55 mm Hg) and maximal tourniquet pressures (186.91 ± 12.91 mm Hg vs. 200.69 ± 15.55 mm Hg) were significantly lower, the time required to estimate AOP and set the tourniquet cuff pressure was significantly less (23.91 ± 4.77 s vs. 178.81 ± 25.46 s) in Group II (p = 0.000). No complications that could be related to the tourniquet were observed during or after surgery. CONCLUSION: Tourniquet inflation pressure setting based on AOP estimation method provides a bloodless surgical field that is comparable to that of LOP determination method with lower pneumatic inflation pressure and less required time for cuff pressure adjustment in adult patients undergoing total knee arthroplasty under combined spinal epidural anesthesia.

Obese patients require higher, but not high pneumatic tourniquet inflation pressures using a novel technique during total knee arthroplasty.

OBJECTIVES: This study aims to investigate the effect of obesity on pneumatic tourniquet inflation pressures determined with a novel formula during total knee arthroplasty (TKA). PATIENTS AND METHODS: Data of 208 patients (19 males, 199 females; mean age 69.8 years; range, 53 to 84 years) who were performed TKA between January 2013 and December 2016 were evaluated prospectively. Patients were divided into two groups as non-obese (body mass index [BMI] ≤30.0 kg/m2) and obese (BMI >30.0 kg/m2) according to BMI. Tourniquet inflation pressures were set using arterial occlusion pressure (AOP) estimation method and adding 20 mmHg of safety margin to AOP value. All patients were assessed intra- and postoperatively with outcome measures such as systolic blood pressure, AOP, tourniquet pressure and its effectiveness. The quality of the surgical field and complications were assessed by the surgical team in a blinded fashion. RESULTS: The study included 118 and 90 lower extremity operations in obese and non-obese groups, respectively. Compared to non-obese group; extremity circumference, initial and maximal systolic blood pressures, AOP values, initial and maximal tourniquet pressures were higher in obese group. The performance of the tourniquet was assessed as "excellent" and "good" at almost all stages of the surgical procedure in all patients in both groups. No complication occurred intra- or postoperatively. CONCLUSION: Compared to non-obese patients, higher tourniquet inflation pressure is required in obese patients during TKA due to their wider extremity circumference and higher systolic blood pressure profile.

Does severe osteoarthritis in knees with varus deformity alter the adductor ratio?

OBJECTIVE: In our retrospective study, we aimed to investigate the differences between the adductor ratio (AR) in knees with and without osteoarthritis, and its validity in determining the articular level. METHODS: Data from 80 knees of 80 patients were retrospectively evaluated. Anteroposterior weight-bearing knee radiographs of the patients with and without osteoarthritis (40 knees in each group) were obtained. The adductor ratio was determined using the following formula: ATJL/FW (adductor tubercle-joint line distance/femoral width). All radiographs were evaluated at the baseline and at one-month intervals afterwards. Intraobserver reliability of the two measurements was assessed using interclass correlations (ICC). Pearson's correlation test was used to evaluate the correlation between the ATJL and the FW. The differences between the adductor ratios of the two groups were evaluated by the independent samples two-tailed t-test. RESULTS: Most of the ICC values were well above 0.95, indicating a very high intraobserver reliability. The adductor ratio was significantly greater in Group 2 in comparison to Group 1 (Mean AR in Group 2: 0.522 ± 0.031 and Mean AR in Group 1: 0.502 ± 0.032; p = 0.005). There was a significant correlation between the ATJL and FW in the groups when assessed both separately and combined. CONCLUSION: In conclusion, we can assert that if the AR is used to determine the articular level in revision arthroplasty cases, it may be sensible to measure the FW intraoperatively rather than measuring it on primary or contralateral radiographs of arthritic patients. LEVEL OF EVIDENCE: Level III, Diagnostic study.

Proximal tibiofibular joint pain versus peroneal nerve dysfunction: clinical results of closed-wedge high tibial osteotomy performed with proximal tibiofibular joint disruption.

PURPOSE: Closed-wedge high tibial osteotomy (CW-HTO) requires shortening of the fibula or the fibular head or disruption of the proximal tibiofibular joint (PTFJ). However, no study has evaluated the proximal tibiofibular joint after the osteotomy. The aim of this study was to investigate the fate of the PTFJ after CW-HTO applied with using PTFJ disruption method. METHODS: This prospective study included 22 knees of 20 patients who underwent CW-HTO. The mean age of the patients was 50 ± 4 years, and the mean follow-up period was 27.5 ± 14.3 months (12-46 months). The grade of gonarthrosis (Ahlbäck's classification), tibiofemoral alignment and tibial slope angles were measured on radiographs pre- and post-operatively. During the surgery, the PTFJ capsule was released meticulously so as not to injure the peroneal nerve. Tenderness over the PTFJ was recorded preoperatively and at the last follow-up. RESULTS: No patient had tenderness or pain over PTFJ preoperatively. On the follow-up examinations, tenderness with compression was detected in nine knees with dorsiflexion, in ten with plantar flexion and in nine with neutral position of the ankle, respectively. None of the patients had peroneal nerve injury (including hypesthesia and mild weakness) post-operatively. However, while 11 knees were pain free in all positions of the ankle, seven knees had tenderness over PTFJ both in dorsiflexion and in plantar flexion. CONCLUSION: CW-HTO using PTFJ disruption provides good clinical results in terms of medial knee pain and corrects the alignment sufficiently while avoiding peroneal nerve injury. However, the results of this study indicated that this technique might result in painful PTFJs. Thus, the surgeon should consider a possibly painful PTFJ, which can be a cause of chronic lateral knee pain when performing this technique. LEVEL OF EVIDENCE: III.

A rare complication of total knee arthroplasty: Type l complex regional pain syndrome of the foot and ankle.

Complex regional pain syndrome (CRPS) is a painful and disabling disorder that usually affects the extremities. This complication may affect the knee joint after total knee arthroplasty (TKA). We report a unique case of CRPS of the foot and ankle, which was an unusual involvement site for CRPS after TKA.

A novel hybrid type (custom-made plus off-the-shelf) total femoral PROSTALAC.

INTRODUCTION: Treatment of periprosthetic joint infection following revision-Total Hip Arthroplasty is more problematic when there is poor bone quality and severe bone loss. Migration of revision prosthesis with a long stem to the knee joint in infected cases makes treatment more complex. In these cases, total femoral replacement is the only treatment option and eradication of infection is mandatory before the replacement. In 2-staged reconstruction treatment, there is a need for a PROSTALAC to replace the whole femur. METHODS: We describe here a novel hybrid type (custom-made plus off-the-shelf) total femoral PROSTALAC for cases in need of whole femoral bone and femoral component removal for the treatment of periprosthetic joint infection in total hip arthroplasty. RESULT: Both sides of the PROSTALAC have anatomical joint surfaces, so the articulation with the acetabulum proximally is expected to be more stable. The off-the-shelf anatomic joint surface of the PROSTALAC distally allows articulation compatible with a proximal tibial off-the-shelf spacer. CONCLUSIONS: This simple hybrid-type total femoral PROSTALAC can be adjusted to femoral length, has anatomical joint surfaces that produce a more stable articulation, and can articulate with an off-the-shelf proximal tibial spacer.

Practice of tourniquet use in Turkey: a pilot study.

OBJECTIVE: The aim of the present pilot study was to evaluate patterns in the current practice of tourniquet use in Turkey. The results of this study can provide detailed information regarding tourniquet use and evaluate the need for guidelines on tourniquet use in Turkey. METHODS: The questionnaire was sent to orthopedic residents and surgeons by either giving printed questionnaires directly or by establishing preliminary communication with surgeons and then sending questionnaires by e-mail. Participating staff consisted of 3 groups: Group 1: orthopedic surgeons; Group 2: orthopedic residents; and Group 3: orthopedic academic staff. Statistical differences in tourniquet use were analyzed among the groups. RESULTS: Use of mechanical tourniquet was significantly higher in Group 1. Plain cuffs were used in orthopedic surgical practice more frequently. Assistant and orthopedic theatre personnel were commonly reported by participants as the tourniquet applicant. Periodic educational practice was not routine. The number of reported complications was higher in Group 3. Cuff padding was generally routine practice. Scientifically valid options at lowest inflation pressure were not observed among the results at the expected rates. CONCLUSION: The results of this pilot study indicate that there is wide variation in some aspects of tourniquet practice in Turkey. The differences are not acceptable because of the potential for significant complications with some practices. There is a need to provide and ensure adequate education to provide the best patient care. Furthermore, protocols should be developed for acceptable standards of tourniquet use.

Clinical utilization of arterial occlusion pressure estimation method in lower limb surgery: effectiveness of tourniquet pressures.

OBJECTIVE: The effectiveness of the arterial occlusion pressure (AOP) estimation method to set tourniquet inflation pressures was assessed in patients undergoing lower limb surgery. METHODS: One hundred ninety-eight operations were performed in 224 lower extremities of 193 patients. Tourniquet inflation pressures were set using the AOP estimation formula and adding 20 mmHg of safety margin to AOP value. Primary outcome measures were the amount of tourniquet pressure and its effectiveness. The quality of the surgical field and complications were assessed by the surgical team in a blinded fashion. Secondary measures included the time required to set the tourniquet pressure and complications. RESULTS: The initial and maximal tourniquet pressures used were 168.4±14.5 and 173.3±15.6 mmHg, respectively. The performance of the tourniquets was assessed as "excellent" and "good" in all stages of the procedure in 97.76% of cases. The time required to measure AOP and set the tourniquet cuff pressure was 19.0±2.6 sec. No complications occurred during or after surgery until discharge. CONCLUSION: Clinical utilization of the AOP estimation formula is a practical and effective way of setting tourniquet pressures for lower limb surgery. Its usage allows achievement of a bloodless field with inflation pressures lower than those previously recommended in the literature for lower limb tourniquets.

Hand injury with a nail gun: a case report with literature review.

The nail gun was introduced in the late 1950s to increase the ease of driving nails, studs, bolts, or staples into various hard surfaces. The nail gun is a potentially dangerous device that is still commonly used in the construction industry. Since its introduction, an increasing number of studies have reported injuries associated with nail guns. Nail gun-related injuries-such as to the head, neck, and chest-can be devastating, and in some cases, even fatal. Extremity injuries, notably in the hand, can cause loss of function, missed work, and long-term health effects. This case report describes a nail-gun injury of the hand along with a discussion of the unique features of and treatment strategies for nail gun injuries.

An investigation of consistency between posterior condylar axis +3 degree external rotation line and clinical transepicondylar axis line techniques in primary total knee arthroplasty.

OBJECTIVES: This study aims to investigate discrepancy between posterior condylar axis (PCA)+3 degree external rotation (ER) line and clinical transepicondylar axis (cTEA) line and consistency between the both techniques in primary total knee arthroplasty. PATIENTS AND METHODS: Thirty-six knees [Bilateral knees were operated simultaneously in 12 patients (50%)] in 24 patients [3 men (12.5%), 21 women (87.5%); average age 67 (59-80 age)] were included in the study. During surgery, PCA+3° ER line and cTEA line were drawn on the distal femoral cutting surface by electrocautery pencil following distal femoral cut. The both lines on distal femur were recorded by digital camera and relationship between lines was ascertained in reference to PCA+3° ER line [parallel, internal rotation (IR), ER]. Statistical analysis was performed by the McNamara chi square test and Kappa (κ) value. RESULTS: Assessment of the images revealed that cTEA line in comparison to PCA+3° ER line was parallel in 22 knees (61.2%), but not parallel in 14 knees (38.8%) [IR in 10 knees (71.5%), ER in 4 knees (28.5%)]. There was a significant difference (McNamara chi square=12.7±1; p<0.001) and poor consistency (κ=0.00055) between both lines and techniques, respectively. CONCLUSION: For determination of femoral component rotation in surgery setting, different results between cTEA and PCA+3° ER techniques possibly may due to disadvantages of techniques and anatomic variation of distal femur. Thus, using both techniques to check each other's results seems unsafe.

Osteochondroma of the talus: an unusual location.

Osteochondroma rarely affects talus although it is the most common primary bone tumor. We report a case of talar osteochondroma in a 6 year-old boy. There was no recurrence two years after the local resection of the lesion.

Bilateral periprosthetic distal femoral fractures following total knee arthroplasty.

Periprosthetic supracondylar femur fractures following total knee arthroplasty are infrequent, but challenging to clinicians. In this article, we present a 74-year-old female case of bilateral supracondylar femoral periprosthetic fractures which were treated with locking plates. The fractures were healed with osseous union, the range of motion was 0-110° for each knee, and there was a 6° residual varus deformity in the left knee. The functional results were excellent during two-year follow-up. Open reduction and locking plate fixation are effective treatment methods for periprosthetic supracondylar fractures following total knee arthroplasty in selected patients. If an anterior femoral notching accidentally develops during the intraoperative setting, using a femoral component with an attached intramedullary stem supports weakened distal part of the femur.

Stenosing tenosynovitis of the peroneus brevis tendon associated with hypertrophy of the peroneal tubercle.

Stenosing peroneal tenosynovitis is not an uncommon ailment. It has a number of different causes, one of which is hypertrophy of the peroneal tubercle. In this report, we present a case of stenosing tenosynovitis of the peroneus brevis tendon associated with hypertrophy of the peroneal tubercle without involvement of the peroneus longus tendon. The condition was fully resolved by means of operative treatment.

A contribution to Pisani's sign for diagnosing lateral meniscal cysts: a technical report.

This article describes modified physical examination maneuvers for diagnosing lateral meniscal cysts. The typical presentation of lateral meniscal cysts usually makes their clinical diagnosis simple, but a wide variation in size may sometimes lead to misdiagnosis. We evaluated the effect of leg rotations on the cystic swelling at 45 degrees of knee flexion. Eleven consecutive patients with positive Pisani's sign were evaluated prospectively. Lateral mid-third joint-line swelling was most prominent at 30-45 degrees of knee flexion. With the knee held at 45 degrees of flexion, the prominence was also inspected during internal and external rotation of the leg. The masses became noticeably more prominent with external rotation, and completely disappeared with internal rotation. With external rotation of the leg, even doubtful lateral meniscal cysts became apparent. Disappearance of the cystic mass with internal rotation further confirms the diagnosis.

Clinical evaluation of the proximal tibiofibular joint in knees with severe tibiofemoral primary osteoarthritis.

Despite the coexistence of primary arthritic involvement of the tibiofemoral and proximal tibiofibular joints (PTFJ), clinical features of the PTFJ in knees with severe femorotibial arthritis have not been described to date. The PTFJ in knees with primary osteoarthritis may be a source of lateral knee pain after total knee arthroplasty operations. This study seeks to address whether there is a relationship between the clinical findings and degeneration of the PTFJ in knees with severe tibiofemoral primary osteoarthritis. Sixty knees in 34 consecutive patients (31 females and 3 males; mean age 71 years; range 61-86 years) with Kellgren-Lawrence grades III-IV primary femorotibial arthritis were enrolled in this study in order to collect clinical data regarding the PTFJ. Radiographs showed 23 PTFJs were grade IV, 14 were grade III, and 23 were grade II. With regard to the type of PTFJ, 13 joints were horizontal and 47 were oblique. Pain and tenderness were observed in 13 PTFJs upon clinical exam (two horizontal and 11 oblique PTFJ types; grade II in five, grade III in two, and grade IV in six). Lateral hamstring tightness was found in 28 knees (24 oblique and four horizontal PTFJ types; grade II in 10, grade III in two, and grade IV in 16). Ten of the 28 PTFJs in knees with lateral hamstring tightness were painful during the physical examination. No significant relationship was found between PTFJ exam findings and PTFJ type (Fisher's Exact test, p=0.713), PTFJ grade of arthritis (chi(2) test, p=0.700), or between hamstring tightness and PTFJ type (chi(2) test, p=0.194). However, hamstring tightness was significantly correlated with the grade of arthritis in the PTFJ (chi(2) test, p=0.004). Although degenerative disease of the PTFJ is commonly associated with degenerative disease of the knee joint, radiographic findings of the PTFJ in patients with severe degenerative knee osteoarthritis and varus malalignment do not correlate with clinical findings.

Foot and ankle injuries and time lost from play in professional soccer players.

BACKGROUND: Ankle and foot injuries are common in professional soccer players, but the relation among diagnosis, severity and time lost from play is not well known. OBJECTIVE: The aim of this study is to investigate the relationship among diagnosis, injury severity and time lost to play of professional soccer players with severe ankle and foot injuries with reviewing the recent literature. DESIGN: Retrospective descriptive study. PATIENTS AND METHODS: Collected data of 66 players with severe ankle and foot injuries were included in the study. Type of injury, diagnosis, treatment, injury severity and finally, time lost from play were evaluated from the medical records. Injury severity ('severe' if >28 days, 'moderate' if between 8 and 28 days) and time lost from play were calculated from medical records and by telephone interviews with the players. RESULTS: Most injuries (n=20, 32%) occurred during player-to-player contact. The most common diagnosis was ankle sprain (30.3%) with anterior talofibular ligament injury. Most (55%) hindfoot injuries were Achilles tendinopathy with or without rupture. Treatment was surgical in 23 patients (35%). The mean time lost from play for players with severe foot and ankle injuries was 61 days (range 21-240 days); after Achilles tendon ruptures, the mean time lost was 180 days. Injury severity was severe (>28 days lost from play) in 64% patients and moderate (8-28 days lost from play) in 36% patients. CONCLUSION: Time lost to play can dramatically increase by the presence of severe ankle and foot injuries. Serious ankle and foot injuries in this study resulted in players being out of professional competition for about 2 months.