Should We Suture Arthroscopic Portals? Effects on Intra-articular Fluid Retention.

Knee arthroscopy is one of the most common surgical procedures in orthopaedics and especially in sports medicine. Portal problems and effusion after knee arthroscopy have been reported. The fluid retention within the joint in knee arthroscopy can affect clinical outcomes, but there is no consensus on portal management. The studies of portal management in knee arthroscopy have mainly addressed wound healing and cosmetic problems. There is insufficient information in the literature about whether the irrigation fluid used in this effusion contributes to the process. This study investigates whether arthroscopic irrigation fluid is retained in the joint and whether portal-closure management has an effect on effusion. In this randomized, prospective study, 91 patients (46 [50.5%] sutured-portal group and 45 [49.5%] open-portal group) were included. Suprapatellar knee-diameter measurement and the number of times the dressing was changed were used to assess intra-articular fluid collection. The visual analog scale (VAS) score, Oxford knee score, and Knee Society score were used to evaluate knee problems. All portal wounds in both groups healed without any problems. Superficial or deep infection was not observed in either group. There was no statistically significant difference in VAS score, Oxford knee scores, and Knee Society scores between groups. Although there was a decrease in the knee diameter of both groups between the early postoperative period and first postoperative day, a statistically significant difference in knee diameter was found, especially in the open-portal group. There was a significant difference between the groups in terms of the number of dressings used in the first 24 hours after surgery. Leaving portals open may be effective in preventing intra-articular fluid retention. We thus advise leaving the arthroscopy portals open with just a simple dressing for selected patients.

Reproducible and Reliable Method for Syndesmotic Screw Fixation: An MRI-Based Cross-Sectional Image Analysis.

Ankle arthrosis may be an unexpected potential result in syndesmotic injuries because of instability and malreduction. For anatomical reduction and stabilization, a reliable and stable reference point is crucial to correctly place syndesmotic screw. The aim of this study was to determine a reliable reference point and to quantify the ideal angle for placement of the screw. In this prospective cohort study, 99 healthy volunteers underwent right ankle magnetic resonance (MR) imaging. On the axial sections, the ideal axis of the syndesmotic screw and other reference points were depicted with 4 lines and 2 angles which were evaluated at the level 2 cm above the tibial plafond. Values were recorded by 2 independent observers to assess for interobserver reliability. The mean value of syndesmotic screw position according to the ground line was 28° ± 6.4° like Arbeitsgemeinschaft für Osteosynthesefragen suggestion. Furthermore, it was determined that the syndesmotic screw could be placed more precisely in the position when placed at an angle of 26.2° ± 1.1° with the axis perpendicular to the line passing through the anterior tibial and Achilles tendons. Ideal syndesmotic screw positioning must be stable enough in case not to be affected by lower extremity alignment deficiencies or foot deformities. So, the anterior tibial and Achilles tendons can be used as reproducible and reliable landmarks for the placement of syndesmotic screws.

Does the Type of Surgical Technique and the Use of Prophylactic Antibiotics Affect the Clinical Results in Symptomatic Ingrown Toenail Patients?

Ingrown toenails are a common reason for referral to orthopedics and podiatry clinics. Recurrence and infection are common complications in ingrown toenail surgery. This study investigates the effect of an electrocautery matrixectomy on the recurrence and clinical outcomes in the Winograd technique applied in ingrown toenail surgery and whether prophylactic antibiotic use is necessary for these surgeries. One hundred forty-three patients who underwent surgery for ingrown toenails were analyzed retrospectively. Eighty-two patients underwent the Winograd procedure with electrocautery matrixectomy, whereas 61 patients underwent the Winograd procedure. While 78 patients were given prophylactic antibiotics, 65 patients were not. Patient satisfaction was evaluated with a surgical satisfaction questionnaire (SSQ). A visual analog score was used to evaluate the pain. Recurrence was observed in 3 toenails in the Winograd and electrocautery groups, while recurrence was observed in 9 toenails in the Winograd group (P = .018). In both groups, there was no statistically significant difference between the infection rates between patients who took antibiotics and those who did not (P > .05). There was no statistically significant difference between the groups in terms of SSQ scores (P > .05). It was observed that the surgery performed had a positive effect on pain, and this effect was statistically highly significant in both groups (P < .05). The outcomes of the present study suggest that the addition of an electrocautery matrixectomy to the Winograd technique in the surgical treatment of symptomatic Ingrown toenails may decrease recurrence rates. Additionally, this study showed that oral antibiotics, when used in addition to Ingrown toenail surgery, do not reduce postoperative morbidity.

Posterior Border Distance: An Effective Diagnostic Measurement for Carpal Tunnel Syndrome Using Ultrasonography.

Purpose The purpose of this study was to define posterior border distance (PBD), which represents an ultrasonographic diagnosing method of carpal tunnel syndrome (CTS), and to determine the reliability of PBD in comparison with electromyography (EMG) results. Methods Thirty-three patients (mean age: 51.8 ± 9.5 years; 27 females and six males) with CTS were included in this study. Ultrasonography (US) and EMG were performed under blinded conditions. PBD was evaluated by measuring the length of the perpendicular line between the posterior border of the median nerve and the line between the hook of the hamate and trapezoid tubercle. The cross-sectional area, anteroposterior (AP), and transverse diameter of the median nerve were measured. Control US was performed in 20 patients who were available at the first year postoperative follow-up and the results compared with preoperative US values. Correlation analyzes were performed to determine the relationship between electrodiagnostic results and ultrasonographic measurements. Results According to the results of preoperative and postoperative first-year US, there were statistically significant differences in the results of PBD (preoperative: 3.309±1.7472 mm, postoperative: 2.290±0.7867 mm p: 0.013) and AP diameter of the median nerve (preoperative: 3.012±0.7865 mm, postoperative: 2.680±0,5578 mm p: 0.017). There was no statistically significant difference in transverse diameter (preoperative: 6.585±1.9505 mm, postoperative: 6.955±2.2128 mm) and cross-sectional area (preoperative: 14.33±6.513 mm2, postoperative: 11.20±5.830 mm2) results (p>0.05). The cut-off value of PBD was ≥3.6 mm, it yielded 81.48% specificity and 83.33% sensitivity in the diagnosis of CTS. PBD was correlated with motor and sensory latency, anteromedial, and transverse diameter of the median nerve (p<0.05). There was no correlation between EMG values and the results of the cross-sectional area, transverse diameter, and AP diameter of the median nerve (p>0.05). Conclusion PBD is suggested as a reliable ultrasonographic measurement method for the diagnosis of CTS.

The effect of platelet-rich plasma on fracture healing in long-bone pseudoarthrosis.

PURPOSE: The aim of this study was to investigate the effects of platelet-rich plasma (PRP) on fracture union rate and fracture union time in pseudoarthrosis surgery and to evaluate the clinical and functional results of the patients. METHODS: The patients who were undergone pseudoarthrosis surgery between 2011 and 2014 were evaluated retrospectively. Twenty-four patients were included in the study. Patients were divided into two groups with used PRP and not used PRP during surgery. There were 14 patients in the PRP group and 10 patients in the control group. The two groups were compared in terms of demographic characteristics, fracture union time, and functional scores of the Lower Extremity Functional Scale and Upper Extremity Functional Index. RESULTS: Fractures were healed in both groups, and no complications were encountered. A statistically significant difference was found between the two groups in terms of fracture union time. The mean time of union was 5.3 months in the PRP group and 11.3 months in the control group (p: 0.000). There was no statistically significant difference between the two groups in terms of functional scores (p: 0.250). CONCLUSION: As a result of our study, we concluded that PRP is an effective and safe method in pseudoarthrosis surgery that reduces fracture union time. Controlled studies with more patient numbers are needed.

Is electromagnetic guidance system superior to a free-hand technique for distal locking in intramedullary nailing of tibial fractures? A prospective comparative study.

BACKGROUND: Intramedullary nailing (IMN) technique is the gold standard for the treatment of closed fractures of the lower extremity long bones. For orthopedic surgeons, one of the most important problems in IMN procedures is the fixation of distal locking screws (DLS). Accurate and rapid placement of DLSs with minimal radiation exposure is crucial. In this study, we aimed to compare the results of two different distal locking methods concerning surgery duration and radiation exposure in patients who underwent osteosynthesis of tibia fractures with IMN. METHODS: In this prospective study, the results of 56 patients who met the inclusion and exclusion criteria from 72 patients were evaluated. Patients were divided into two groups according to the distal screwing method. Group 1 (n=29) comprised patients who used free-hand technique (FHT) for distal locking, while Group 2 (n=27) consisted of patients who used electromagnetic guidance system (EMGS) for distal locking. Demographic and medical data of the patients, duration of surgery time, amount of bleeding, total fluoroscopy counts, the time elapsed for distal locking, the measure of radiation exposure, number of attempts for distal screw locking, incorrect screw placements, complications and follow-up time were recorded. The groups were compared concerning demographic data and clinical results. RESULTS: There was no statistically significant difference between the groups about gender and side (p=0.928 and p=0.432, respectively). The mean age in Group-1 was higher than that of Group-2, and the difference was statistically significant (p=0.012). However, there was no statistically significant difference in length of hospital stay in Group-1 (p=0.140). On the other hand, in Group-2, the number of distal shots, fluoroscopy duration, effective radiation dose and operation duration were lower compared to Group-1, although this difference was not statistically significant (p=0.057, 0.073, 0.058 and 0.056, respectively). Failure was encountered in distal locking during the first attempt in three cases in Group-1 and in two cases in Group-2. Aseptic nonunion was observed in one patient in both groups. CONCLUSION: Both the FHT distal screwing technique and the EMGS distal screwing technique are highly effective methods for distal locking. The duration of operation, the duration of the fluoroscopy and radiation exposure were similar. FHT can be preferred for distal locking in conventional intramedullary nail applications, as it is effective, easy and inexpensive.

Clinical, radiological and patient-reported outcomes in intra-articular calcaneal fractures: Comparison of conservative and surgical treatment.

OBJECTIVES: This study aims to compare the radiological, clinical and patient-reported outcomes of patients with intra-articular calcaneus fractures treated conservatively or surgically. PATIENTS AND METHODS: Fifty-four patients (30 males, 24 females; mean age 41.0 years; range, 18 to 73 years) treated due to calcaneus fracture were included in the study. Twenty-nine patients underwent conservative treatment (group 1) and 25 patients underwent surgical treatment (group 2). The fractures were classified according to Sanders. At the final follow-up, patients' Bohler's angle, The American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score and Foot Function Index (FFI) were used to evaluate their radiological, clinical and patient-reported outcomes. Postoperative complications were also noted. RESULTS: The fracture was at the right foot in 28 patients and the left foot in 26 patients. The mean follow-up duration was 41.1±23.2 months (range, 24 to 126 months). No statistically significant differences were found between the groups in terms of gender, fracture side, mean age, or follow-up duration (p=0.951, p=0.571, p=0.326, and p=0.620, respectively). According to Sanders classification, 18 patients were type 2 and 11 patients were type 3 in group 1, while 11 patients were type 2 and 14 patients were type 3 in group 2. However, there was no statistically significant difference between the groups in terms of the type of the fracture (p=0.184). On the other hand, the outcomes were significantly better for group 2 compared to group 1 in terms of the Bohler's angle, AOFAS and FFI scores (p=0.004, p=0.003 and p=0.006, respectively). In group 1, subtalar arthritis developed in three patients. In group 2, wound healing problems and superficial infection developed in three patients, while subtalar arthritis developed in two patients. CONCLUSION: Surgical treatment is more effective in intra-articular calcaneus fractures compared to conservative treatment according to clinical, radiological and patient-reported outcomes. In addition, wound problems should be considered in surgical management.

Outcomes of isokinetic tests and functional assessment of anterior cruciate ligament reconstruction: Transtibial versus single anatomic femoral tunnel technique.

OBJECTIVE: The aim of the study was to compare the outcomes of the transtibial and anatomical femoral single tunnel surgical techniques in ACL reconstruction. METHODS: A total of 30 patients, with 16 patients (15 males and 1 female; mean age: 27.2 ± 7.04) with anatomical femoral single-tunnel technique (AFT) and 14 (12 males and 2 females; mean age: 29.4 ± 8.82) with transtibial technique (TT) were included into the study. All patients were evaluated with isokinetic tests at an angular velocity of 60°/s and 180°/s and the IKDC and Lysholm tests were performed preoperatively and in third, sixth, and 12th months postoperatively. The results were compared between the groups. The mean follow-up time was 17.1 ± 6.48 months. RESULTS: Postoperative third month changes in extension parameters of peak torque (AFT: -93.286, TT: -61.500), peak work (AFT: -77.071, TT: -47.500), peak torque ext/kg (AFT: -1.182, TT: -0.773), peak work ext/kg (AFT: -0.982, TT: -0.604), peak work (AFT: -55.143 TT: -33.063) at an angular velocity of 60°/s and postoperative third month change in extension parameter of peak power (AFT: -86.786 TT: -54.875) at an angular velocity of 180°/s were found to be better in the transtibial group (p < 0.05) and postoperative sixth month peak torque (AFT: 1.429, TT: -5.688) value at an angular velocity of 60°/s was found to be less in the anatomical femoral single-tunnel group (p < 0.05). The IKDC (AFT: 94.671, TT: 90.025) (p < 0.05) and Lysholm (AFT: 96.714, TT: 92.375) (p < 0.05) scores of the anatomical femoral single-tunnel group were better than the transtibial group regarding to the postoperative final follow-up. There are positive intermediate correlations between preoperative IKDC and Lysholm scores with preoperative and postoperative some isokinetic test ratio (r = 0.539; p = 0.031), and preoperative peak power extension (r = 0.541; p = 0.030) at the both angular velocity of 60°/s and 180°/s in the transtibial group. There was no significant difference between the two groups with regards to the Lachman, anterior drawer and pivot shift tests (p < 0.05). CONCLUSION: There were differences in terms of isokinetic parameters in early outcomes but there was no statistical difference between isokinetic parameters at the end of 1st year between two groups. There were some correlations between IKDC and Lysholm scores with some isokinetic parameters. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

Effects of Zoledronic Acid Treatment on Fracture Healing, Morbidity and Mortality in Elderly Patients with Osteoporotic Hip Fractures.

BACKGROUND: In this study, the effects of zoledronic acid (ZolA) administered at different times to patients undergoing surgical treatment for hip fracture were investigated. MATERIALS AND METHODS: Ninety patients who underwent surgical treatment for osteoporotic (OP) hip fractures between February 2013 and September 2016 in our hospital were included in the study. After surgical treatment, patients were allocated into three groups: group I-patients who had osteosynthesis using proximal femoral nail (PFN) for an intertrochanteric fracture of the femur were given ZolA within 1 week after fracture and before discharge; group II-patients who had osteosynthesis using the PFN for an intertrochanteric fracture of the femur were given ZolA within 1 month after fracture post-discharge; group III-patients in the same age group who had a hemiarthroplasty (HA) for an intertrochanteric fracture of the femur were administered ZolA before discharge. In addition, all patients were given daily oral calcium and vitamin D3. The Radiographic Union Score for Hip (RUSH), Harris Hip Score (HHS), and bone mineral density (BMD) were used at the follow-up as evaluation criteria, and complications were noted. RESULTS: There were no significant differences between groups in terms of demographic data and laboratory outcomes (p > 0.05). Radiographic Union Score for Hip scores were similar between groups I and II (p > 0.05). Fracture union occurred by the sixth month in all patients whose results were evaluated. No statistically significant difference was found between three groups (p > 0.05). There was no difference between the three groups in the hip and vertebrae BMD and t scores (p > 0.05). When t and BMD scores before treatment were compared with those at 1 year after treatment, a benefit from ZolA treatment was observed in all three groups (p < 0.05). CONCLUSION: This study shows that the timing of ZolA administration has no effect on fracture healing and complication incidence in elderly patients with hip fractures. In addition, ZolA was found to be beneficial in increasing BMD of both femur and vertebra in all groups, but there was no significant difference between the groups. CLINICAL SIGNIFICANCE: The study demonstrated that ZolA may be used early in the treatment of osteoporotic hip fractures with PFN. HOW TO CITE THIS ARTICLE: Sargin S, Konya MN, Gulcu A, et al. Effects of Zoledronic Acid Treatment on Fracture Healing, Morbidity and Mortality in Elderly Patients with Osteoporotic Hip Fractures. Strategies Trauma Limb Reconstr 2019;14(3):126-131.

Endoscopic versus Open Bursectomy for Prepatellar and Olecranon Bursitis.

Objectives Bursitis of the olecranon and the patella are not rare disorders, and conservative management is successful in most cases. However, when patients do not respond to conservative treatment, open excisional surgery or, recently, endoscopic bursectomy, can be used. The aim of this study was to evaluate the results of open and endoscopic treatments of olecranon and prepatellar bursitis. Patients and methods Forty-nine patients (37 male and 12 female), who were treated with endoscopic bursectomy (25 patients) or open bursectomy (24 patients) were included in this study. Thirty patients had olecranon bursitis, while 19 patients had prepatellar bursitis. The patients' average age was 61.1 ± 12.3 (range 33-81) years. All of the patients' hospitalization and surgery times were recorded. The satisfaction of the patients was evaluated with a satisfaction scoring system, as well as by evaluating residual pain, the range of joint movement, and the cosmetic results of the procedure. Results The average follow-up time was 16 ± 9 months (range 12-27). The median operation time was 23.2 ± 3.5 minutes for the endoscopic bursectomy group and 26.4 ± 6.8 minutes for the open bursectomy group. The median hospitalization time was 0.56 ± 0.5 days (range 0-1 day) for the endoscopic group and 1 ± 0 days for the open bursectomy group (P<0.01). According to the patient satisfaction questionnaire, the endoscopic bursectomy group's score was 8.5 ± 1.3 (range 5-10), and the open bursectomy group's score was 5.29 ± 1.8 (range 1-9) (P<0.01). Conclusion Endoscopic bursectomy is a time-saving and efficient surgical treatment option for patients with prepatellar and olecranon bursitis.

Efficacy of extracorporeal shockwave therapy in patients with lateral epicondylitis: A randomized, placebo-controlled, double-blind clinical trial.

OBJECTIVE: Lateral epicondylitis is a common elbow problem. Although extracorporeal shockwave therapy (ESWT) is widely used in the treatment of lateral epicondylitis, its efficacy is still controversial. Moreover, the number of prospective, randomized, controlled studies in the literature is not sufficient. Here, we intend to investigate the efficacy of ESWT. METHODS: The study was randomized, placebo-controlled, double-blind, and prospectively planned. Forty patients who met the inclusion criteria were divided into two groups, real ESWT (Group 1, n=20) and placebo ESWT (Group 2, n=20), in a 1: 1 randomized closed envelope manner. Patients were evaluated for Patient-Rated Tennis Elbow Evaluation-Turkish Version (PRTEE-T), visual analog scale (VAS) pain scores, and grip and pinching strengths. The evaluation were performed thrice before, at the end of treatment and 1 month after treatment. Both groups were treated with wrist splinting, ice treatment, and rest. RESULTS: There was no statistical difference between sex and dominant hand in both groups. There was no significant difference in the grasp and pinching strength between the measurements of the groups themselves (p>0.05). When examined in terms of VAS scores, only significant changes were found in the actual ESWT group (p<0.05). According to the PRTEE-T scores, both groups showed significant changes (p<0.05). No significant difference was found between post-treatment and control measures in the grip and pinching power between groups, VAS and PRTEE-T scores before treatment (p>0.05). CONCLUSION: Although pain and functional improvement were more prominent in our patients treated with ESWT than placebo, no statistically significant results were found.

Descending branch of the lateral circumflex femoral artery as a recipient vessel for vascularized fibular grafts: Clinical case series.

Vascularized fibular grafts (VFG) are used for the treatment of femoral head avascular necrosis, osteomyelitis, nonunions, and excessive bone defects. Mostly the ascending branch of the lateral circumflex femoral artery (LCFA) or first or second perforating branch of the profound femoral artery is used for the customary recipient vessel. In this report, an alternative technique of using descending branch of LCFA in VFG surgery and its clinical results are reported. Sixteen patients (13 men and 3 women) underwent VFG surgery between the years 2005 and 2012. Predicted etiologies were: ANFH in 10 hips, traumatic femur neck pseudoarthrosis in 4 hips, tumor in 1 hip, and 1 femur shaft defect due to osteomyelitis. Patients' average age at the time of surgery was 29 years (range, 14-43 years). All patients were treated with VFG. All of the grafts survived and none of the patients needed any revision surgery. One had superficial wound infection, one developed peroneal nerve palsy, and one had trochanteric bursitis. The follow-up time was 36 months (range 20-72). It is believed that the descending branch of LCFA is a reliable alternative for anastomosis in VFG surgery.

Post-traumatic Median Nerve Neuroma in Wrist. A Case Report and brief review of Literature.

INTRODUCTION: Distal median nerve masses may be developed post-traumatic or non-traumatic. In this paper, we aim to present a 52 year old female case with a postraumatic neuroma of the median nerve in the left wrist. CASE SERIES: A 52-year-old female patient had accidental incised wound over her left wrist which was primarily sutured. She presented 6 months later with unrelieved pain and growing swelling at the wrist. USG showed solid mass of size 2x3 cms. Intraoperatively the mass was seen to arise from medial nerve and careful excision was done protecting the nerve. At one year follow up the patient is relived of her symptoms with no sensorimotor deficit. CONCLUSION: Post traumatic neuroma present as unrelieved pain and progressive swelling. A high index of suspicion should be kept in cases of wound that are primarily sutured over an area with superficial nerves. Careful excision of the lesion is very effective in relieving patients symptoms.