The lateralization and distalization index is more reliable than angular radiographic measurements in reverse shoulder arthroplasty.

BACKGROUND: The lateralization shoulder angle (LSA) and distalization shoulder angle (DSA) are used to reproducibly measure lateralization and distalization after reverse shoulder arthroplasty (RSA). However, LSA and DSA may not offer a precise measurement of humeral lateralization and distalization and this relationship has not been explored. The aim of this study was to evaluate the validity of these measurements and to propose new measurement methods to estimate implant lateralization and distalization. METHODS: 3D models were constructed from computed tomography (CT) scans of 30 patients using a software platform. For each patient 24 different RSA modifications were created, resulting in 720 different RSA configurations. For each configuration LSA and DSA angles as well as lateralization and distalization distances were measured. Moreover, for each configuration two new measurements were done: the lateralization index (LI) and distalization index (DI). Correlations of the lateralization and distalization parameters were evaluated between measurements. RESULTS: Weak correlations were founded between LSA and lateralization (r = 0.36, p < 0.01), whereas moderate correlations were observed between LI and lateralization (r = 0.72, p < 0.01). No significant correlations were found between DSA and distalization (r = 0.17, p = 0.113). In contrast, moderate correlations were identified between DI and distalization (r = 0.69, p < 0.01). CONCLUSION: LI and DI are more reliable methods to estimate implant lateralization and distalization compared to angular radiographic measurements. However, the prognostic significance in predicting clinical outcomes after RSA remains unknown.

Morphological Changes in the Tibial Tunnel After ACL Reconstruction With the Outside-In Technique and Adjustable Suspensory Fixation.

Background: Anterior cruciate ligament reconstruction (ACLR) using the complete tibial tunnel technique and adjustable-loop cortical suspensory fixation is known to leave a "dead space" that holds the loop device in the tibial tunnel. The consequence of the dead space and its effect on graft healing are still uncertain. Purpose: To investigate morphological changes in the tibial tunnel and their effect on graft healing, and to identify factors affecting bone healing in the tibial loop tunnel after ACLR with a quadrupled semitendinosus tendon autograft using adjustable suspensory fixation. Study Design: Case series; Level of evidence, 4. Methods: Included were 48 patients (34 male, 14 female; mean age, 25.2 ± 5.6 years) who underwent ACLR with a quadrupled semitendinosus tendon autograft using adjustable suspensory fixation. To evaluate tibial tunnel morphology, computed tomography was performed at 1 day and 6 months postoperatively. At 1 year postoperatively, graft healing was assessed on magnetic resonance imaging using the graft signal-to-noise quotient (SNQ). Multivariate regression and correlation analyses were performed to determine any associations between volumetric changes in bone healing and operative variables. Results: At 6 months after ACLR, a mean of 63.2% of the tibial loop tunnel was filled by bone. Multivariate regression analysis showed that remnant preservation was significantly associated with the loop tunnel filling rate (P < .001). At 1 year after ACLR, the tibial loop tunnel was almost completely closed (98.5%). There were no correlations between loop tunnel volume and graft integration or graft SNQ. A significant but weak correlation was found between graft tunnel volume and intratunnel graft SNQ (P = .10) as well as integration grade in the tibial tunnel (P = .30). Conclusion: Excellent bone filling in the tibial loop tunnel was seen at 1 year after ACLR. Remnant preservation was significantly associated with the loop tunnel filling rate. A weak correlation was found between graft tunnel volume and intratunnel graft SNQ as well as integration grade in the tibial tunnel.

Comparative finite element analysis of four different internal fixation implants for Pauwels type III femoral neck fractures in various fracture angles in the sagittal plane.

OBJECTIVES: This study aimed to evaluate the performance of four different fixation techniques for Pauwels type III femoral neck fractures considering the fracture morphology in the sagittal plane. MATERIALS AND METHODS: We constructed three different fracture morphologies in the sagittal plane in Pauwels type III femoral neck fractures: posteriorly angled at 20°, neutral, and anteriorly angled at 20°. We set up four fixation devices, including three cannulated screws (3CS), a dynamic hip screw with an antirotational screw (DHS+CS), a proximal femoral locking plate (PFLP), and three cannulated screws with a medial buttress plate (3CS+MBP). The twelve models were created and analyzed using the finite element analysis. RESULTS: The finite element analysis revealed that 3CS+MBP yields better results in total vertical and rotational displacements, regardless of the fracture angle in the sagittal plane. For the anterior and posterior angled fractures in the sagittal plane, the PFLP was superior to the DHS+CS. However, the DHS+CS exhibited less displacement than the PFLP in the neutral fracture line in the sagittal plane. The 3CS group demonstrated poor mechanical stability for Pauwels type III fractures. CONCLUSION: Regardless of the fracture line in the sagittal plane, the 3CS+MBP showed better biomechanical behaviors than the 3CS, DHS+CS, and PFLP. In addition, in contrast to the DHS+CS, the PFLP displayed less vertical and rotational displacement in the anterior and posterior fracture lines in the sagittal plane.

The mid-term clinical outcomes of total knee arthroplasty in the management of end-stage hemophilic arthropathy.

OBJECTIVE: This study aimed to evaluate the mid-term clinical outcomes of total knee arthroplasty (TKA) in the management of end-stage hemophilic arthropathy. METHODS: Eleven patients (15 knees) undergoing TKA with stiff knees were retrospectively evaluated. TKA was performed in all patients without additional surgical interventions such as posterior capsular release, hamstring release, synovectomy, VY quadricepsplasty, or tibial tubercle osteotomy. All patients were evaluated for clinical and radiological results at follow-ups. Functional evaluation and pain status were assessed using the Knee Society Score and Visual Analogue Scale. RESULTS: The mean age at the time of operation was 40.8 ± 11.8 years (range=30-64 years). The mean follow-up was 51.2 ± 20.6 months (range=24-95). The mean flexion contracture significantly decreased from 17.6 ± 11.3 to 1.7 ± 2.8 degrees, and the mean maximum flexion increased dramatically from 55.6 ± 20.5 to 109.2 ± 16.2 degrees (P < 0.001). Statistical significant improvement in flexion and flexion contracture degrees continued up to the postoperatively 18 months. The mean Knee Society Score increased from 22.7 ± 2.4 points preoperatively to 87.8 ± 3.8 points at the last follow-up (P < 0.001). The mean cost of coagulation factor consumption and blood transfusion accounted for 78% of the total cost. CONCLUSION: This study has shown that TKA is an effective treatment for relieving pain and improving both ranges of motion and quality of life in managing end-stage hemophilic arthropathy of the knee joint. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Tibial slope, remnant preservation, and graft size are the most important factors affecting graft healing after ACL reconstruction.

PURPOSE: The aim of this study was to determine the anatomic, operative and biological factors that influenced graft healing after single-bundle anterior cruciate ligament (ACL) reconstruction. METHODS: One hundred fourteen consecutive patients who underwent anatomic single-bundle ACL reconstruction with quadrupled hamstring tendon autografts between 2016 and 2019 were retrospectively analyzed. Ninety-four patients met the inclusion criteria with minimum follow-up of 12 months. Patients were evaluated with multiple clinical measurements, including International Knee Documentation Committee Subjective Knee Form (IKDC-SKF), Lyshom Scores, and Marx activity scale. To evaluate graft healing, the signal-to-noise quotient (SNQ) was measured at intra-articular graft and intra-tunnel integration were evaluated on magnetic resonance imaging (MRI) at one year after surgery. Potential factors affecting graft healing, including age, sex, body mass index, time from injury to surgery, posterior tibial slope, lateral femoral condyle ratio, notch width index, meniscal injury, remnant preservation, tunnel aperture locations, graft size, graft bending angle, graft/remaining notch volume ratio were evaluated for their association with graft SNQ value by stepwise regression analysis. RESULTS: A total of 94 patients were evaluated with mean follow-up 28.5 ± 9 months. Univariate regression analysis showed that posterior tibial slope, notch width index, remnant preserving procedure, high femoral tunnel, anterior tibial tunnel, graft bending angle, and graft/remaining notch volume ratio significantly associated with graft SNQ values. Multivariate regression analysis showed that lateral tibial slope, remnant preservation, and graft/remaining notch volume ratio were independent factors correlated with graft SNQ values. Also, the graft SNQ values was weakly correlated with femoral tunnel integration and Marx activity scale at one year. There was no correlation between graft SNQ values and IKDC-SKF and Lysholm scores. There was no correlation between graft SNQ values and International Knee Documentation Committee and Lysholm scores. CONCLUSIONS: Tibial slope, remnant preservation and graft/remaining notch volume ratio were significant independent associated factors of graft SNQ value at one year. The graft SNQ values were also weakly correlated with femoral tunnel integration and the Marx activity scale. These factors should be taken into account for ensuring the ideal graft healing and for the return to sport decision-making. LEVEL OF EVIDENCE: Level IV.

Pseudoparalysis and Acromiohumeral Interval Reversibility Are the Most Important Factors Affecting the Achievement of Patient-Acceptable Symptom State After Arthroscopic-Assisted Latissimus Dorsi Tendon Transfer.

PURPOSE: To determine the patient-acceptable symptom state (PASS) values for American Shoulder and Elbow Surgeons (ASES) score and the Constant-Murley (CM) score after arthroscopic-assisted latissimus dorsi tendon transfer (LDTT) and to identify potential factors affecting the achievement of PASS. METHODS: Fifty consecutive patients who underwent arthroscopic-assisted LDTT between 2015 and 2020 were retrospectively analyzed. In total, 42 patients met the inclusion criteria with minimum follow-up of 1 year postoperative. Patients were evaluated preoperatively and 1-year postoperatively with multiple clinical measurements including ASES, CM, score and PASS. The primary outcome was identified as patient satisfaction which assessed with achievement of a PASS. Potential factors affecting the patient satisfaction including age, sex, body mass index, previous surgery, presence of pseudoparalysis, critical shoulder angle, shoulder abduction moment index, acromiohumeral interval (AHI) reversibility, Hamada grade and fatty infiltration were evaluated for their association with PASS value by stepwise logistic regression analysis. RESULTS: A total of 42 patients were evaluated with mean follow-up 27.8 ± 8.21 months. The ASES and CM scores improved from preoperative means of 21.6 ± 6.5 and 25.2 ± 8.5 to 65.6 ± 20.7 points and 56.8 ± 16.5 points, respectively (P < .001). The PASS values for the ASES and CM scores were 62.4 and 52.5, respectively. The univariate analysis showed that older age (P = .021), presence of pseudoparalysis (P < .001), previous surgery (P = .016), lower preoperative AHI (P = .028), and lower AHI reversibility (P < .001) were all significantly associated with worse patient satisfaction. The multivariable logistic regression analysis showed that pseudoparalysis (P = .038) and AHI reversibility (P = .021) were independent prognostic factors affecting the achievement of a PASS after arthroscopic-assisted LDTT. The cutoff value for AHI reversibility to predict an achievement of PASS was found to be 4.0 mm. CONCLUSIONS: Arthroscopic-assisted LDTT led to satisfactory results in patients with massive rotator cuff tears. However, pseudoparalysis and AHI reversibility were the most important independent prognostic factors that consistently reduced and increased, respectively, the odds of achieving a PASS. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Treatment of knee osteochondritis dissecans with autologous tendon transplantation: Clinical and radiological results.

BACKGROUND: Defect treatment with tendon autograft in osteochondral lesions has been published in the literature with an experimental study in dogs. To demonstrate that it is possible to treat knee osteochondral lesions with the technique of autologous tendon transplantation. AIM: To evaluate the clinical and radiological results of patients with knee osteochondral lesions who were treated with autologous tendon transplantation. METHODS: Twenty patients (22 knees) with osteochondritis dissecans (OCD) lesions involving the knee were treated with autologous tendon transplantation between 2005-2018. All lesions were International Cartilage Repair Society grade IV. All patients were evaluated clinically at final follow-up with knee injury and osteoarthritis outcome score (KOOS); and radiologically with magnetic resonance observation and cartilage repair tissue (MOCART) and Kellgren-Lawrence (KL) classification. RESULTS: A total of 20 patients (22 knees) with a mean age of 25.5± 6.8 years were included. The average defect size was 4.2 ± 2.1 cm2, and the average defect depth was 0.9 ± 0.4 cm. Total KOOS score was preoperatively 29.4 ± 5.5 and was later found to be 81.5 ± 5.9 after an average of 68.7 ± 37.7 mo follow-up. The mean MOCART score was 56.2 ± 10.7. Preoperatively, all of the patients had KL grades of 0-1; during the follow-up period, 80% of the patients showed no radiological progress of osteoarthritis. Patients with less than 4 cm2 lesion had statistically significantly better overall KOOS than patients whose more than 4 cm2 lesion, particularly in sport and quality of life subscales. CONCLUSION: The autologous tendon transplantation is a single-step, safe, simple, cost-effective method for the treatment of knee OCD with satisfactory clinical and radiological outcomes, particularly in patients with less than 4 cm2 lesion.

Avascular Necrosis of Humeral Trochlea: A Case Report of the Rare Condition.

INTRODUCTION: Avascular necrosis of humeral trochlea is a very rare condition and was described by Hegemann in 1957. We reported two cases of avascular necrosis of humeral trochlea and also performed a literature review of the reported cases. We expect that this case report will assist clinicians in making a timely diagnosis when encountering similar clinical scenarios. MATERIALS AND METHODS: We presented cases of an 11-year-old and a 14-year-old with avascular necrosis of the humeral trochlea. The common etiology was idiopathic because there were no recent trauma history and sports activity. Also, there was no history of drug use. We discussed the clinical and radiological findings of these cases. RESULTS: These cases, two teenage boys, were diagnosed withHegemann's disease with clinical and radiological outcomes. We found that the etiology of both thecases is idiopathic;. The number of previously reported cases in the literature is limited to 64. In our study, there was a lateral crest in one of our two cases and a posteromedial involvement in another. The radiograph of trochleae of these two cases showed irregularity and granular appearance. In our case, heterogeneous signal changed and irregularities were accompanied by hypointensive changes on T1-weighted images. Also, hyperintensive changes on proton density sequences were detected. CONCLUSION: Radiological evaluation plays an important role in the diagnosis and evaluation of response to treatment in avascular necrosis of the humeral trochlea. Avascular necrosis should be one of the differential lesions involving the trochlea. Recognition of avascular necrosis in the trochlea may prevent the unnecessary biopsy.

Effectiveness and reliability of traditional open surgery in atypical localizations of osteoid osteoma.

OBJECTIVES: This study aims to evaluate traditional open surgery results of osteoid osteomas (OOs) in atypical localizations and explore whether open surgery can be a safe alternative in localizations where radiofrequency ablation (RFA) may not be suitable. PATIENTS AND METHODS: A total of 26 patients (20 males, 6 females; mean age 23.3±14.2 years; range, 4 to 65 years) having OO in atypical localizations between January 2008 and January 2017 were retrospectively evaluated. All patients underwent traditional open surgery under anesthesia. All patients were followed-up, and their clinical success and complications were evaluated. The pain intensity was assessed using the visual analog scale (VAS). RESULTS: The postoperative first year VAS score was 0.2±0.5 (range, 0-2) (p<0.005). None of the patients showed any complications. No recurrences were reported at the end of the first year. All patients were relieved from pain due to OO in atypical localizations. CONCLUSION: Although RFA has been accepted as the preferred treatment for OO, traditional open surgery may still be used for OO in atypical localizations yielding perfect clinical results with fewer complications. It is a safe alternative for localizations such as carpal bones, distal ulna, hand and foot where RFA complications can be seen more frequently. In these localizations, traditional open surgery can be recommended as the first treatment choice.

Editorial Commentary: What is the Difference That Makes the Differences? The Practical Rationality of the All-Suture Anchor.

Suture anchor technologies are constantly being innovated in the quest for improved stability, biological integration and clinical outcomes. However, the decision about the choice of suture-anchor materials remain elusive. There are some factors, including reliability, effectiveness, simplicity, familiarity, and cost, that affect a surgeon's preference. The relative weights placed on different factors by different surgeons play decisive roles in individual choice. But decisions and choices are not arbitrary or merely subjective. Alternative options can be warranted or contested by rational argumentation. At the end, there may be losses and gains in the change of 1 suture anchor for another, but science does progress.

Metatarsal Head Restoration With Tendon Autograft in Freiberg's Disease: A Case Report.

Freiberg's disease is a form of osteochondrosis of a metatarsal head that often affects the second metatarsophalangeal joint, and that affects females more often than males. Repetitive microtrauma, osteonecrosis, and stress overload are the main factors in its pathophysiology. Surgical intervention is indicated in advanced cases wherein nonoperative treatment has failed. In this report, we describe the case of a young female who had Freiberg's disease localized to the third metatarsal head bilaterally and who was successfully treated with peroneus longus tendon transplantation.

Predicting postoperative pain with neutrophil/ lymphocyte ratio after arthroscopic rotator cuff repair.

BACKGROUND: Postoperative pain is well known and usually disturbing complication of arthroscopic shoulder surgery. Inflammation plays an important role in the development and progression of postoperative pain. The aim of this study was to evaluate the predictability of postoperative pain through the correlation of neutrophil/lymphocyte ratio (NLR) with inflammation. In addition, the correlation of parameters such as operative time, tear size, age and gender with postoperative pain was evaluated. METHODS: Sixty three patients, who underwent arthroscopic rotator cuff repair, were evaluated in this single-center-based retrospective study. The American Society of Anaesthesiologists I and II risk groups were determined as the inclusion criteria. NLR was calculated using preoperative one day hemogram values in all patients. The amounts of analgesic use and Numerical Rating Scale (NRS) scores at the 12th, 24th and 48th hours and on the 3rd and 7th days were recorded. Multivariate linear regression analysis was used to correlate postoperative NRS scores with multiple independent factors, including preoperative NLR, sex, age, tear size, repair type, operative time, block time, postoperative analgesic intake and length of hospital stay. RESULTS: Sixty three patients with a mean age of 59.4 years (range, 40-72 years) were evaluated. The mean tear size was 2.8 cm (range, 1-5 cm), the mean operative time was 84.1 min (range, 35-135 min), the mean duration of block was 7.6 hours (range, 4-12 hours) and the mean length of hospital stay was 1.7 days (range, 1-3 days). There was no significant correlation between age, sex, tear size, repair type, operative time and postoperative NRS (p > 0.2). The preoperative NLR was found to be a strong predictor of postoperative NRS (p < 0.001, rho = 0,864). There was a correlation between the NLR and mean analgesic intake (p = 0,03). The duration of block was decreased in patients with a NLR above 2, while it was prolonged in patients with a NLR below 2 (p = 0.04, rho = -0,725). CONCLUSION: The preoperative NLR was found to be a strongest factor predicting high acute pain levels after arthroscopic rotator cuff surgery. Likewise, NLR was also predictive of postoperative block time and analgesic consumption.

Extensor mechanism reconstruction with peroneus longus tendon autograft for neglected patellar fracture, report of 2 cases.

Extensor mechanism deficiency in the knee may occur due to neglected patellar and quadriceps tendons rupture or may be caused by chronic fractures of the patella. Older patients can tolerate nonunion with impaired function including extension limitation or persistent muscle weakness. In young patients, performing rigid internal fixation with reoperation should be considered when a nonunion occurs. However, delayed and neglected nonunion in patella fractures require performing different surgical procedures. We report two cases, operated for a patella fracture, in whom nonunion occurred and accompanied by patellar migration and retraction of quadriceps tendon because of a fixation failure. We reconstructed the extensor mechanism with peroneus longus tendon autograft and, owing to this method, we achieved excellent functional results during a 2-year follow-up period.

Arthroscopic glenoid labral lesion repair using all-suture anchor for traumatic anterior shoulder instability: short-term results.

BACKGROUND: This study presents the preliminary clinical results of arthroscopic glenoid labral lesion repair using all-suture anchors in the treatment of recurrent traumatic anterior shoulder instability. METHODS: Seventy patients who underwent arthroscopic shoulder stabilization for traumatic anterior shoulder instability were evaluated in this single center-based retrospective study. Patients with a glenoid defect greater than 20%, off-track engaging Hills-Sachs lesion, multidirectional instability, and generalized ligamentous laxity were excluded. The 62 included patients treated with arthroscopic glenoid labral lesion repair using all-suture anchors were evaluated. The Rowe and Constant scores were used to assess the results. RESULTS: We evaluated 62 patients with a mean age of 26.7 ± 12 years. The mean Rowe and Constant scores were 35 ± 7.2 and 65 ± 6.3, respectively, preoperatively and increased to 93.6 ± 5.3 and 92 ± 4.3, respectively, postoperatively at the mean follow-up of 28.8 months (range, 24-48 months) (P < .001). The redislocation rate was 8.1%. Of the patients, 91.9% had good to excellent clinical scores. Younger age and contact sports were associated with a higher risk of recurrent dislocation (P = .012 and P = .041, respectively). The postoperative functional results were not significantly correlated with the findings concerning the number of dislocations, time until surgery, degree of anterior translation, and number of anchors. CONCLUSION: The use of all-suture anchors for arthroscopic glenoid labral lesion repair for the treatment of recurrent traumatic anterior shoulder instability yields satisfactory clinical results and is a safe and effective option.