Use of Tibial Cortical Autograft for the Osteotomy Site in Medial Opening-Wedge High Tibial Osteotomy.

Background: Medial opening-wedge high tibial osteotomy (OWHTO) is a useful treatment option in patients with medial compartment osteoarthritis. Typically, the osteotomy site is filled with material such as autologous bone graft, allograft, or synthetic bone substitute. However, all these options have disadvantages. Purpose/Hypothesis: The purpose of this study was to describe tibial cortical autograft as an alternative to conventional graft options. It was hypothesized that the tibial rectangular cortical bone that is removed from the proximal medial cortical surface of the distal tibial fragment longitudinally could be a reliable option for recovery of the gap in the osteotomy area. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 520 patients with medial compartment osteoarthritis who underwent OWHTO between June 2009 and March 2019 were retrospectively analyzed. Patients were divided into 3 groups according to the graft material used to fill the osteotomy site: allograft in group A, iliac crest autograft in group B, and tibial autograft in group C. Bone union, evaluated by radiographs performed at 2 weeks, 4 weeks, 2 months, 3 months, 6 months, and 1 year postoperatively, was defined as occurring when at least 50% of the gap site was bridged with callus. Clinical assessment was performed using the International Knee Documentation Committee (IKDC) and Lysholm scores. Results: Included were 122 patients: 40 patients in group A, 42 patients in group B, and 40 patients in group C. The mean correction was 13.87°± 3.58° in group A, 12.33°± 3.92° in group B, and 14.10°± 2.99° in group C. The mean time for radiological bone union was 6.95 ± 1.40 months in group A, 4.48 ± 1.02 months in group B, and 5.07 ± 1.70 months in group C. Patients in all groups had similar IKDC and Lysholm scores at the final follow-up. Conclusion: This is the first report of this specific procedure in the literature. All clinical and radiological findings showed that use of tibial cortical autograft was an efficient method in patients undergoing OWHTO.

Utilizing Surgeon-Performed Intraoperative Translaryngeal Ultrasound for Verifying Vocal Fold Function: A Troubleshooting Approach for Intraoperative Neuromonitoring in Neck Surgery.

INTRODUCTION: We investigated transcutaneous laryngeal ultrasonography (TLUS) for assessing vocal fold (VF) mobility during thyroid and parathyroid surgeries, emphasizing its precision and utility in signal loss scenarios. METHODS: Between October 2020 and January 2023, we performed TLUS, Doppler sonography, laryngeal twitch response (LTR) palpation, and electromyography (EMG) to monitor recurrent laryngeal nerve function during neck surgeries. Postoperatively, the VF activity was verified using fiberoptic video laryngoscopy (FL). Concordance with FL was categorized based on VF activity. RESULTS: Of the 443 VF evaluations, no instances of permanent bilateral paralysis were noted. Temporary unilateral palsy was found in 3.38% and permanent in 0.45%. TLUS displayed 97.8% agreement with EMG and was diagnostically superior (99.7% vs 98.2%) and more affordable ($68 vs $300) compared to analogous operative durations. CONCLUSION: TLUS rivals EMG in terms of intraoperative neuromonitoring accuracy and outperforms LTR. Being cost-effective, TLUS can effectively address signal loss situations, thereby averting additional surgeries.

Predicting coexisting thyroid cancer with primary hyperparathyroidism in an endemic region of multinodular goiter: evaluating the effectiveness of preoperative inflammatory markers.

Purpose: The aim is to examine the efficacy of inflammatory indicators to predict thyroid cancer in patients with primary hyperparathyroidism (PHPT) in an endemic region of nodular goiter. Methods: The prospective database was reviewed to identify patients operated on with the diagnosis of PHPT and thyroid disease between April 2015 and June 2021. Permanent pathologic reports were used as the gold standard for diagnosis. Detailed imaging data with peripheral blood inflammation indices were analyzed to assess their predictive values for concomitant PHPT with thyroid cancer. Postoperative complications and the duration of hospitalization were also reviewed. Results: Thyroid malignancy accompanying PHPT was found in 13 patients (26.0%) out of 50 who had concurrent surgery. The analysis regarding inflammatory indexes revealed nothing significant between thyroid cancer and preoperative blood biochemistry (P > 0.05). In the concurrent surgery group, recurrent laryngeal nerve injury was observed in 1 patient (2.0%) and the mean hospital stay was longer. Conclusion: In endemic regions of nodular thyroid disease, thyroid cancer might accompany PHPT. The value of inflammatory indexes to predict thyroid malignancy in PHPT is controversial and should not be employed in the surgical decision-making process.

Tibial cancellous bone auto-grafting for medial open-wedge high tibial osteotomy: bone void filling with tissue harvested from osteotomized medullary canal.

The aim of the study was to evaluate the clinical and radiological outcomes in a series of patients undergoing open wedge high tibial osteotomy (OWHTO) using tibial cancellous autograft harvested from the osteotomized medullary canal which is not reported in the literature before. Patients with medial compartment osteoarthritis were treated with OWHTO and tibial cancellous auto- grafting performed from the osteotomized medullary canal and used for bone void filling. Seventy patients (seventy-two knees) treated with OWHTO were analyzed. All patients started partial weight-bearing with crutches the day after surgery and full-weight bearing eight weeks after surgery, according to radiological evaluation. Fifty-seven women and 13 men with a mean age of 54.2±8.1 years were evaluated in this study. The mean correction angle was 8.4±2.5° (range: 5.3°-14.3°). The osteotomy sites of all patients were grafted with tibial cancellous autografts. In all patients bony union was detected after surgery. No implant failures or major complications were en- countered. Clinical and radiological findings revealed that bone void filling with the harvested autograft from the osteotomized medullary canal may be a satisfactory and reliable option in OWHTO.

Humeral fractures sustained during arm wrestling.

PURPOSE: The aim of this study was to present our experience of treating humerus fracture sustained during arm wrestling. METHODS: Data of patients treated in our clinic with the diagnosis of humeral shaft fracture due to arm wrestling between 2000 and 2020 was retrospectively reviewed. Data collected included age, sex, dominant arm, history of professional or experienced participation, type and laterality of fracture, presence of radial nerve palsy, other surgical complications, management (surgical or conservative), duration of union defined as the time from injury until callus was evident on the radiograph, and the range of motion of the elbow joint at the last follow-up. RESULTS: Nineteen patients with humeral shaft fracture as a result of the arm wrestling were included. All had right arm fracture and all had right as the dominant side. All of the fractures were spiral at the distal third of the humerus and medial butterfly fragment was present in eleven (57.9%). Seven (36.8%) were treated surgically. Five (26.3%) had radial nerve palsy on admission. At last follow-up, no patient had neural deficit and none had significant loss of range of movement. CONCLUSION: Arm wrestling is an important cause of humerus shaft fracture. The dominant side is invariably affected. In this series all fractures were spiral type and occurred in the distal third of the humerus. One quarter of patients experienced radial nerve palsy, which can resolve spontaneously. Satisfactory results can be obtained with both conservative and surgical treatment. LEVEL OF EVIDENCE: IV.

A comparison of EFECE systems with tension band wiring for patella fracture fixation in cadavers.

BACKGROUND: EFECE systems are newly defined internal fixation systems, which are suitable for patella fracture fixation. The aim of this study was to compare the fixation strength of EFECE Systems with tension band wiring for transverse patellar fracture simulation on fresh frozen cadaver models. METHODS: Quadriceps tendon-patella-patellar tendon (QT-P-PT) complex was prepared from human cadavers. After simulation of a transverse patella fracture, in group 1, 5 patella were fixed with a pair of 1.2 mm EFECE wires and 4 EFECE devices. In group 2, 5 patella were fixed with a pair of 1.2 mm Kirschner wires (K-wire) and a cerclage wire according to the tension band technique. Using a testing device with custom-made jaws, increasing distraction force was applied to these QT-P-PT complexes. Extension of these complexes with the distraction forces was observed. The maximum distraction force and the elongation during maximum force were evaluated. RESULTS: After 5 experiments with the EFECE systems, there was no EFECE wire breakage or EFECE wire-EFECE device catching failure. The median maximum force was 740 N (720-810 N). During maximum distraction force the median extension was 2.5 mm (1.6-2.5 mm). After 5 experiments with the tension band technique, there was no K-wire breakage. The median maximum force was 330 N (240-510 N). During this maximum distraction force the median extension was 3.4 mm (2.2-3.8 mm). CONCLUSIONS: Based on the biomechanical advantages, patella fracture treatment with EFECE systems may constitute a reasonable alternative in the treatment of patella fractures.

Carpometacarpal fracture dislocation of the fourth and fifth finger: mid-term results of 15 patients.

OBJECTIVES: This study aims to retrospectively evaluate and compare the mid-term clinical follow-up results of patients who were treated with open or closed reduction due to carpometacarpal (CMC) fracture dislocation. PATIENTS AND METHODS: Medical charts of 15 patients (1 male, 14 females; mean age 32.5±10.5 years; range 18 to 55 years) who were operated for fourth and fifth finger CMC fracture dislocations were examined. Patients were divided into two groups according to applied treatment as closed reduction and percutaneous pinning (CRPP, n=6) and open reduction and percutaneous pinning (ORPP, n=9). Patients were assessed by a hand therapist blinded to the treatment groups. Patients were compared in respect of visual analog scale (VAS), Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) scores, and grip strength. Complications were recorded. RESULTS: Mean VAS values of ORPP group and CRPP group were 2.33±0.50 and 1.67±0.52, respectively. Mean Q-DASH values of ORPP group and CRPP group were 13.63±3.21 and 9.05±2.36, respectively. Mean grip strength values of ORPP group and CRPP group were 65.78±3.70 and 75.17±6.11, respectively. Mean VAS and Q-DASH scores of ORPP group were statistically significantly higher compared to CRPP group. Mean grip strength value of CRPP group was statistically significantly higher compared to ORPP group. CONCLUSION: Treatment of fourth and fifth finger CMC fracture dislocations with CRPP results in statistically superior VAS, Q-DASH and grip strength values in the early post-injury period.

Anterior and Posterior Vertebral Column Resection Versus Posterior-only Technique: A Comparison of Clinical Outcomes and Complications in Congenital Kyphoscoliosis.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: The purpose of this study is to compare the anterior-posterior surgery to posterior-only vertebra resection for congenital kyphoscoliosis in pediatric patients. SUMMARY OF BACKGROUND DATA: Vertebral column resection is a very powerful correction technique mainly used in the treatment of severe and rigid spinal deformities. The technique can be applied with combined anterior and posterior vertebral column resection (APVCR) or posterior-only vertebral column resection (PVCR) approaches. PVCR has gained popularity recently due to several apparent advantages, but APVCR is still believed by some to be a viable alternative, despite the use of an anterior exposure. MATERIALS AND METHODS: A retrospective chart and radiographic review was performed including the patients with congenital kyphoscoliosis up to 16 years of age who were operated on by a single senior surgeon in our department after 2005. The data included surgical time, estimated blood loss, duration of hospital and postoperative intensive care unit stay, intraoperative and postoperative complications. Preoperative, postoperative, and follow-up radiographs were evaluated for scoliosis, kyphosis, and spinal balance. RESULTS: Twenty-six patients (20 girls, 6 boys) met the inclusion criteria. APVCR was performed on 17 (median age, 13.2 y) and PVCR on 9 (median age, 10.7 y). Scoliosis correction at the time of last follow-up was 54.3% and 52.6% for APVCR and PVCR, respectively, whereas the average kyphosis correction was 25.4 degrees in APVCR and 30.1 degrees in PVCR group. Surgical time, hospital stay, and estimated blood loss were all significantly higher in the APVCR group, whereas the complication rates were similar. No neurological or vascular complications were encountered. CONCLUSIONS: This study showed that although the operative time and surgical blood loss were higher with APVCR, there were no major complications and the radiologic outcomes were similar between APVCR and PVCR. APVCR should be considered as an acceptable technique especially in deformities where PVCR would be technically difficult or at the beginning of the spine surgeon's learning curve. LEVEL OF EVIDENCE: Level III.

A Case of a Gastrointestinal Stromal Tumor Diagnosed at the Postpartum Period.

Introduction. We discuss a rare gastrointestinal stromal tumor (GIST) case detected at the 10th postpartum week and we want to pay attention to the challenges and improvements in the diagnosis, surgery, chemotherapy, and follow-up of this rare tumor accompanied with the review of the current literature. Case Presentation. A 32-year-old multiparous woman presented with abdominal swelling 10 weeks after her second vaginal birth. Abdominal examination revealed a mass starting from the pelvic level and extending to the right upper quadrant. Radiological examinations showed a solid, multiloculated, and hypervascular mass starting from the pelvis and extending to the transverse colon. En bloc mass with a 20 cm jejunal segment resection and a left pelvic side wall peritonectomy with omentectomy was performed. The pathologic examination revealed a high-risk GIST which originated from the jejunum and disseminated to the peritoneum. The patient has been given imatinib 400 mg/day since then. She did not reveal any progression during the 15-month follow-up postoperatively. Conclusion. GIST tumors are rare and there is not sufficient information in the literature regarding its management. In this patient having high risk GIST and GIST sarcomatosis we successfully treated the patient by surgery and adjuvant imatinib chemotherapy.

Effect of pentoxifylline on healing of segmental bone defects and angiogenesis.

OBJECTIVE: The aim of this study was to determine the effect of pentoxifylline (PTX) on angiogenesis and the healing of a critical-sized segmental defect of the radius diaphysis in a rat model, using radiological and histological grading systems. METHODS: The study included 24 female Sprague-Dawley rats (weight: 300±20 g) divided into 4 groups. A critical-sized segmental defect was created in the radius diaphysis in all rats. In Group 1, morcellized iliac crest autografts were used to fill the segmental bone defect. In Group 2, segmental bone defects were filled using morcellized iliac crest autografts, and 25 mg/kg/day PTX was applied intraperitoneally. In Group 3, the segmental bone defects were not filled, and in Group 4 the segmental bone defects were left unfilled, and an intraperitoneal (IP) dose of 25 mg/kg/day PTX was applied. Rats were sacrificed at postoperative Week 8, and defects were evaluated using radiographic, histological and immunohistochemical methods. RESULTS: There were significant differences between Group 1 and 2 according to radiological evaluation (p=0.003) and quality of union at the defect site (p=0.01). Union quality was higher in Group 4 than Group 3 (p=0.01). Cluster of differentiation 31 (CD31) and vascular endothelial growth factor (VEGF) levels were higher in Group 2 than in Groups 3 and 4. CONCLUSION: According to radiological and histological parameters, PTX appears to improve angiogenesis and healing of segmental cortical bone defects of the radius in a rat model.

Aneurysmal bone cyst-like areas as a sign of metastatic disease in the spinal column.

Aneurysmal bone cysts (ABCs) are vascular lesions with well-defined radiological signs. A fairly common MRI finding in both ABC and other primary bone tumors with high vascularity is the presence of cysts with fluid-fluid levels. Metastatic lesions with fluid-fluid leveling have not previously been defined in the literature. We report three cases of fluid-fluid leveling of the axial skeleton in metastatic lesions. Two patients had single-level and one multi-level neoplastic disease with distinctive cysts showing fluid-fluid levels on MRI evaluation. Diagnosis of gastric carcinoma in two patients and breast carcinoma in the third was achieved with trocar biopsies. At the time of this report all patients had completed initial oncologic treatments and were disease free.

The effect of pedicle screw insertion at a young age on pedicle and canal development.

STUDY DESIGN: A longitudinal case study. OBJECTIVE: To determine whether pedicle screws placed in an immature spine exert effect on the continued growth of the vertebral body. SUMMARY OF BACKGROUND DATA: Pedicle screws have revolutionized surgical treatment of spinal deformities by allowing a mode of secure fixation that provides consistently better correction rates in adults and adolescents. In the young child, however, the trajectory of pedicle screws takes them through an open physis: the neurocentral cartilage. There exists little information regarding the possible effect of pedicle screws inserted at a young age on further development of the spine and the spinal canal. METHODS: Patients undergoing pedicle screw instrumentation of at least 2 levels before the age of 5 years (60 mo) for the first time for any diagnosis and who had been followed for at least 24 months were included. Measurements were performed in instrumented and adjacent noninstrumented levels without visible deformity in pre- and postoperative cross-sectional images and compared using statistical methods. RESULTS: Ninety segments in 15 patients met the inclusion criteria (average age at instrumentation 46.3 mo [range, 29-60 mo]). Forty segments had no screws and 50 had at least 1 screw. Pedicle length and vertebral body diameter had significantly increased in both groups, whereas spinal canal parameters did not change significantly. No significant difference was observed between the growth rates in levels with or without screws in pedicle length, vertebral body diameter, or spinal canal parameters (anterior-posterior and interpedicular diameters, and area). CONCLUSION: Pedicle screw instrumentation performed before the age of 5 years does not cause a negative effect on the growth of pedicles, the transverse plane of the vertebral body, or the spinal canal. It can be safely performed in the treatment of deformity in this age group.

Biomechanical comparison of conventional technique versus oblique screw placement in plate fixation.

BACKGROUND: The aim of this study was to evaluate whether plate fixation with screws in an oblique fashion would change the strength of the fixation to bending forces and whether any relationship existed between deformity and increased strength of fixation. METHODS: Rear leg tibias from 2-year to 3-year-old sheep were affixed with the help of a custom-made guide to a six-hole dynamic compression plate and divided into three groups. In group 1, fixation was performed using screws perpendicular to the plate axis in two planes. In group 2, screws were placed at a 20-degree angle to the axis of the shaft and perpendicular to the transverse plane. In group 3, the screws were placed at a 20-degree angle to the shaft axis and 7 degrees on the transverse plane. Gap-close bending and side-bending tests were performed in a three-point bending fashion. The maximum moment of force and deformation at the time of the failure was analyzed. RESULTS: In gap-close bending tests, mean maximum moment of forces for groups 1, 2, and 3 was 51.90 Nm, 67.47 Nm, 82.05 Nm, respectively (p<0.05 for group 1 vs. groups 2 and 3; p=0.053 for group 2 vs. group 3). In side-bending tests, the mean maximum moment of force was 34.63 Nm, 49.91 Nm, and 49.29 Nm, respectively (p<0.05 for group 1 vs. groups 2 and 3; no significant difference was observed between groups 2 and 3). When the two bending tests were evaluated together, only the mean moment of forces of groups 1 and 3 were statistically different (p=0.006). There was no difference between any groups in terms of the deformity at the time of the maximum moment of force. CONCLUSION: Oblique screw placement in two planes increases the strength of the plate-screw fixation under bending forces; however, there is no relationship between deformity and increased strength of fixation.

Congenital midline upper lip sinus.

The congenital upper lip sinuses are rare and they have previously been reported only in 40 cases. We have presented a case report of congenital midline upper lip sinus in an elderly age. Although the treatment modality is very easy and successful in any cases, the etiology of this rare congenital situation has been obscure and further studies should be done to find out.