Early movement does not cause loss of reduction in surgically treated boxer fractures.

BACKGROUND: The surgical treatment of fifth metacarpal fractures, especially using Kirschner (K) wire techniques, has recently become popular because it provides for early hand movement. Successful anatomical reduction of the fracture is often achieved with surgery; however, an anatomical reduction cannot always be achieved and, according to 30° oblique radiography, the fracture is fixed with an apex dorsal angulation below 40°. The aim of this study was to evaluate the stability of such fractures postoperatively and compare the two different angulation options that provide early movement of the hand and wrist. METHODS: Thirty consecutive cases of neck fractures of the fifth metacarpal were treated intramedullarly with one K wire. Cases were divided into two groups: One fixed with anatomical reduction (Group 1) and the other (Group 2) fixed in apex dorsal angulation below 40°, according to 30° oblique radiography. Angulation, shortening, and functional outcome as Quick DASH scores and grip strengths were evaluated at 6 months. RESULTS: The mean correction angle was 56.6° (between 30° and 110°) for Group 1 and the residual angle was 0°. The mean cor-rection angle was 42.4° (between 20° and 75°) for group 2 (Figs. 4 and 5) and the residual angle was 23.6° (between 10° and 45°). The mean Quick DASH scores were 1.9 (SD: 1.7) for Group 1 and 5.67 (SD: 2.93) for Group 2 (p<0.05). Grip strength values were similar for both groups. All the patients returned to their previous occupations without any limitations in an average of 4 weeks (SD: 1.4) (range 2-6 weeks). No complications such as correction loosening or shortening were detected. Rotation was not detected during physical examination. CONCLUSION: Our investigation revealed no risk of shortening or rotation of the fracture; the patients were able to return quickly to their everyday activities.

The videos on YouTube® related to hallux valgus surgery have insufficient information.

BACKGROUND: Previous studies have determined the videos on YouTube® have misleading information in medicine, however the assessment of the information for hallux valgus surgery is lacking. METHODS: YouTube® was analyzed using two keywords as 'hallux valgus surgery' and 'bunion surgery'. Once redundancies were eliminated, each video was evaluated for the characteristic as following: duration, number of views, likes and dislikes, days since upload, view and like ratios and video power index (VPI). The quality of the information was evaluated using DISCERN, JAMA and hallux valgus score (HVS). RESULTS: A total of 49 videos included. Fair or poor results for DISCERN and HVS (90% and 69% of videos, respectively) were found. No difference was found between video source and quality scores. Number of likes and VPI negatively correlated with all scores (p < 0.001). CONCLUSIONS: YouTube® had poor quality of information for hallux valgus surgery.

Assessment of the Quality and Reliability of the Information on Rotator Cuff Repair on YouTube.

INTRODUCTION: YouTube® has become a common health information source for patients. Recent studies have determined that videos on YouTube® contain misleading and inappropriate information for different medical conditions. The aim of the present study was to assess the quality and reliability of videos pertaining to rotator cuff (RC) repair surgery. HYPOTHESIS: YouTube® users prefer watching videos with high educational quality which are provided by physicians. MATERIAL AND METHODS: A search was performed using keywords "rotator cuff surgery" and "rotator cuff repair" on YouTube® and the first 100 videos for each keyword were analyzed. Video source, time since upload, duration, and number of views, likes, and dislikes were recorded. Video popularity was reported using the video power index (VPI) and view ratio. Video educational quality was measured using the recognized DISCERN, the Journal of the American Medical Association (JAMA) score and a novel RC-specific score (RCSS). RESULTS: Among the 200 videos identified, 67 were included. The mean duration was 7.7minutes and the mean number of the views was 147,430. Videos uploaded by a physician had significantly higher DISCERN, JAMA, and RCSS (p<0.001). While the main video source was physicians (48%), the most popular videos were uploaded by patients and commercial websites, according to the VPI and view ratios. The number of likes, view ratios, and VPI were negatively correlated with each score. There were negative correlations between duration and VPI scores, and positive correlations with DISCERN, JAMA score, and RCSS. Animated videos showed significantly lower results for all quality scores (p<0.05), while their VPI was significantly higher (p<0.01). DISCUSSION: Online information on RC repair surgery provided by YouTube® was low quality, despite being mostly uploaded by physicians and having relatively higher quality scores. YouTube® users prefer watching low quality videos which were provided by patients and commercial websites. LEVEL OF EVIDENCE: IV, Case series.

Minimal invasive fixation of distal tibial fractures does not result in rotational malalignment: A report of 24 cases with CT imaging.

BACKGROUND: Tibial torsion is rotation of the proximal versus the distal articular axis in the transverse plane. This study used computed tomography (CT) to examine rotational malalignment in the crus following use of minimally invasive plate osteosynthesis (MIPO) technique in distal tibial fractures and evaluated effect of rotational difference on clinical outcomes and VAS scores. METHODS: Analysis of 24 patients who were operated on for closed distal tibial fracture with MIPO technique between 2010 and 2012 was conducted. Malrotation was defined as rotational difference >10°. Operated knees were evaluated with 0.5-mm, fine-cut, 3-dimensional CT scan performed in cooperation with radiology department. Side-to-side difference in tibial torsion angle >10° was considered significant degree of malrotation. All patients were assessed clinically (visual analogue scale [VAS] and American Orthopaedic Foot and Ankle Society [AOFAS] scores) and radiologically at final visit. RESULTS: Mean follow-up period was 20.00±9.46 months (range: 18-51 months). Mean VAS score was 2.58±0.83 (range: 1-4) and mean AOFAS score was 87.50±4.05 (range: 78-93). Mean tibial rotation angle was 31.54±6.00° (range: 18-45°) on healthy side and 32.00±6.24° (range: 10-43°) on the operated side. No statistically significant difference was determined (p>0.05). CONCLUSION: Use of intraoperative fluoroscopy, cable technique, and uninjured extremity as reference, can reduce incidence of rotational malalignment of distal tibial fractures treated with MIPO.

Flexor tendon complications in comminuted distal radius fractures treated with anatomic volar rim locking plates.

OBJECTIVE: Anatomic volar rim locking plates are designed with the aim of treating intraarticular distal radius fractures. When used to treat comminuted distal radius fractures, these plates can damage the flexor tendons. In this study, we sought to determine the radiological and functional results and rate of complications of these plates. METHODS: We retrospectively reviewed the records of 36 patients (28 males, 8 females; mean age: 46.4 years) with AO/OTA Type C2-C3 distal radius fractures treated with anatomic volar rim distal radius plates between January 2011 and December 2014. Radial length, radial inclination and palmar tilt were compared with the intact wrist. Results were evaluated with the Mayo wrist and Lidstrom scores. Complications were documented throughout the follow-up period of 23.8 (range: 12 to 48) months. RESULTS: Postoperative measurements of the radial length, inclination and palmar tilt did not differ significantly. Mayo wrist and Lidstrom scores were good and excellent in 27 and 32 patients, respectively. Flexor tenosynovitis was symptomatic in 15 patients and asymptomatic (localized swelling only) in 21. Plates were removed from 15 patients due to symptomatic tenosynovitis and from six patients due to partial rupture of the flexor pollicis longus tendon. The flexor digitorum profundus tendon of the second finger was also partially ruptured in three patients. CONCLUSION: Anatomic volar rim locking plates provide satisfying radiological and functional results in treating AO/OTA Type C2-C3 comminuted distal radius fractures. However, if these plates interfere with the union of the fracture, they should be removed to avoid potential tendon problems caused by their placement in the rim region. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Procedural outcomes of double vs. single fluoroscopy for fixing intertrochanteric femur fractures.

OBJECTIVE: This study compares reducing radiation and operation time between single and double C-arm fluoroscopy in the treatment of intertrochanteric femur fractures with intramedullary nails. PATIENTS AND METHODS: Forty four patients participated in the study. Patients were divided into two groups as single (23 patients) and double fluoroscope (21 patients). The time of preparation, the duration of the surgery, the total amount of blood loss, and the total duration of radiation exposure were compared, retrospectively. The collo-diaphyseal angle was compared with that of the contralateral hip on postoperative radiographs. Furthermore, the tip-apex distance and the position of the screws in the femoral head were recorded. RESULTS: The mean preparation periods, collo-diaphyseal angles and blood loss did not differ between groups. In the double-fluoroscopy group, the duration of surgery was 15.9 min shorter (p < 0.001), and the radiation time was 25.7 s shorter (p < 0.001). CONCLUSION: The double fluoroscopy technique can significantly reduce surgical and radiation exposure times during surgery.

Surgical treatment of dorsal perilunate fracture-dislocations and prognostic factors.

INTRODUCTION: Perilunate injuries are rare entities which can be difficult to diagnose. Most common type is dorsal perilunate fracture dislocation (97%). The purpose of treatment is anatomic reduction and stable fixation. We aimed to present the radiologic and functional results of surgically treated dorsal perilunate fracture-dislocations and discuss the factors influencing the prognosis. METHODS: Between 2007 and 2013, 17 patients were operated for perilunate fracture-dislocations. The mechanism of injuries, soft tissue traumas, etiologic factors and stages according to Herzberg classification were determined. The MAYO wrist score was used for functional evaluation. Scapholunate distance and scapholunate angle were measured and, degenerative changes were investigated by comparing with contralateral side on plain x-ray images in terms of radiologic evaluation. RESULTS: Mean follow-up was 37,8 (range, 16-84) months. The average age at surgery was 35.1 (range, 18-51) years. Fifteen patients were male and two were female. Functional results were excellent in four (23.5%), good in two (11.8%), satisfactory in five (29.4%) and poor in six (35.3%) patients. Degenerative changes were determined in radiocarpal and mid-carpal joints of 14 wrists (82.4%). Scapholunate dissociation more than 2 mm was detected in three wrists. In four wrists osteochondral fragments were determined on the head of the capitate. Stage 2 lesions, delayed presentations, open fractures, scapholunate dissociations more than 2 mm had worse functional results. CONCLUSION: Despite anatomic reduction, ligamentous and chondral injuries that occured at the time of trauma may cause persistant wrist pain in patients who suffer perilunate fracture dislocation. Mechanism of injury, presence of soft tissue defects and the time between injury and treatment can affect clinical and radiologic results.

Hindfoot Valgus following Interlocking Nail Treatment for Tibial Diaphysis Fractures: Can the Fibula Be Neglected?

Purpose. We evaluated whether intramedullary nail fixation for tibial diaphysis fractures with concomitant fibula fractures (except at the distal one-third level) managed conservatively with an associated fibula fracture resulted in ankle deformity and assessed the impact of the ankle deformity on lower extremity function. Methods. Sixty middle one-third tibial shaft fractures with associated fibular fractures, except the distal one-third level, were included in this study. All tibial shaft fractures were anatomically reduced and fixed with interlocking intramedullary nails. Fibular fractures were managed conservatively. Hindfoot alignment was assessed clinically. Tibia and fibular lengths were compared to contralateral measurements using radiographs. Functional results were evaluated using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Foot and Ankle Disability Index Score (FADI). Results. Anatomic union, defined as equal length in operative and contralateral tibias, was achieved in 60 fractures (100%). Fibular shortening was identified in 42 fractures (68%). Mean fibular shortening was 1.2 cm (range, 0.5-2 cm). Clinical exams showed increased hindfoot valgus in 42 fractures (68%). The mean KOOS was 88.4, and the mean FADI score was 90. Conclusion. Fibular fractures in the middle or proximal one-third may need to be stabilized at the time of tibial intramedullary nail fixation to prevent development of hindfoot valgus due to fibular shortening.

Granuloma formation secondary to Achilles tendon repair with nonabsorbable suture.

INTRODUCTION: Several complications can be observed after Achilles tendon repairs. In this study we aimed to report granuloma formation secondary to Achilles tendon repair with Ethibond (Ethicon INC, Somerville, New Jersey) suture. PRESENTATION OF CASE: A 31 year-old man operated for Achilles tendon rupture. The Ethibond suture was used for primary repair. The patient attended to polyclinic with the complaints of swelling and discharge around the operation site four months after operation. A mass around distal portion of the Achilles tendon was detected. The granulomatous tissue was excised. Inside the mass Ethibond suture was detected. On histopathologic examination, typical findings of the foreign body reaction were observed. No microorganism was cultivated in the tissue culture. The patient has no complaint on the twelfth month control after surgery. DISCUSSION: The results of primary repair of Achilles tendon are good but several complications were reported. In tendon repairs generally nonabsorbable sutures are used. The Ethibond is nonabsorbable, braided suture. In the literature, granuloma formations secondary to the suture materials such as polygylactine and braided polyethylen-polyester after Achilles tendon repair were reported but granuloma secondary to the Ethibond is very rare. CONCLUSION: Although Ethibond suture is a strong and safe material for Achilles tendon repairs it may cause soft tissue problems such as granuloma.

Novel axillary approach for brachial plexus in robotic surgery: a cadaveric experiment.

Brachial plexus surgery using the da Vinci surgical robot is a new procedure. Although the supraclavicular approach is a well known described and used procedure for robotic surgery, axillary approach was unknown for brachial plexus surgery. A cadaveric study was planned to evaluate the robotic axillary approach for brachial plexus surgery. Our results showed that robotic surgery is a very useful method and should be used routinely for brachial plexus surgery and particularly for thoracic outlet syndrome. However, we emphasize that new instruments should be designed and further studies are needed to evaluate in vivo results.

Ochronosis diagnosed after knee arthroscopy.

INTRODUCTION: Ochronosis is a rare disorder which is defined as the deposition of metabolites of oxidation and polymerization of homogentisic acid, which have high affinity to collogen, in the connective tissues. It is a clinical condition characterized with ochronotic pigmentation of tissues, degenerative arthropathy of especially large joints and black discoloration of urine. In this paper we present a case of ochronosis diagnosed with biopsy and additional tests when a black discoloration of menisci and joint cartilage were detected during arthroscopic intervention for a degenerative meniscus tear. PRESENTATION OF CASE: A forty two year-old male patient was operated for lateral meniscus tear of his right knee. The arthroscopic examination of right knee revealed black colored synovial hypertrophy and torn lateral meniscus. Partial meniscectomy was performed. The diagnosis of ochronosis was made after histopathologic examination. DISCUSSION: Ochronotic pigment can accumulate in hyaline cartilage, tendon, skin, teeth, nail, sclera, tympanic membrane, heart valves, renal tubular cells, duramater, pancreas and walls of large arteries. In ochronosis the most frequently involved joints are knee and hip. In ochronotic arthropathy, articular cartilage become more sensitive to mechanical stresses. Our patient had meniscal tear, cartilage damage and black discoloration of synovial tissues and meniscus. CONCLUSION: Arthroscopy may be helpful in diagnosis of ochronotic arthropathy.

[Results of arthroscopic repair of triangular fibrocartilage complex peripheral tears (Palmer type 1B)]. / Triangular fibrokartilaj kompleks periferik (Palmer tip 1B) yirtiklarinda artroskopik tamir sonuçlari.

BACKGROUND: Triangular fibrocartilage complex (TFCC) injury is the major cause of wrist pain on the ulnar side. In this study, treatment outcomes of arthroscopically repaired peripheral TFCC tears (Palmer type 1B) were evaluated retrospectively. METHODS: Thirty-eight patients (30 males, 8 females; mean age 27.6; range 19 to 42 years) with TFCC tears (Palmer type 1B) who were treated arthroscopically between February 2007-July 2012 were evaluated retrospectively. The data were collected by Mayo wrist evaluation form and by preoperative and postoperative visual analogue scale (VAS). RESULTS: The results of the data collected by the Mayo wrist evaluation forms were perfect in 30 patients and good in 8 patients. Preoperative VAS was 6.53 (range: 4.5-8.2) and postoperative VAS was 1.48 (range: 0.3-3.1). DISCUSSION: With the arthroscopic technique, TFCC tears can be repaired with minimal harm and better visualization, and evaluation of all the structures of the wrist can be done. Outside-to-inside suturing technique, which is performed through the portal opened 1 cm inferior to the 6R portal, is the least traumatic technique and does not carry the risk of injury to the superficial branch of the ulnar nerve. With this technique, the complaints of preoperative pain can be eliminated significantly.

Medical photography: principles for orthopedics.

BACKGROUND: Medical photography is used clinically for patient evaluation, treatment decisions, and scientific documentation. Although standards for medical photography exist in many branches of medicine, we have not encountered such criteria in publications in the area of orthopedics. PURPOSE: This study aims to (1) assess the quality of medical images used in an orthopedic publication and (2) to propose standards for medical photography in this area. METHODS: Clinical photographs were reviewed from all issues of a journal published between the years 2008 and 2012. A quality of clinical images was developed based on the criteria published for the specialties of dermatology and cosmetic surgery. All images were reviewed on the appropriateness of background, patient preparation, and technique. RESULTS: In this study, only 44.9% of clinical images in an orthopedic publication adhered to the proposed conventions. CONCLUSIONS: Standards have not been established for medical photography in orthopedics as in other specialty areas. Our results suggest that photographic clinical information in orthopedic publications may be limited by inadequate presentation. We propose that formal conventions for clinical images should be established.

Cannulated screw and hexapodal fixator reconstruction for compound upper tibial fractures.

OBJECTIVES: The aim of the treatment of tibial plateau fractures is to obtain a pain-free and fully functional knee with closed reduction, percutaneous cannulated screw fixation and hexapodal external fixator reconstruction for high energy compound upper tibial fractures. METHODS: Patients with comminuted tibial plateau fractures underwent closed reduction, percutaneous fixation with cannulated screws, and reconstruction with hexapodal external fixator. The follow-up period was 24 months. RESULTS: The clinical and radiological results were good or excellent. The average knee flexion was 125°. CONCLUSION: Our results are successful in the initial stage, however, it should be pointed out that during the long term follow-up osteoarthritis may develop leading to worsening of the condition. Level of Evidence IV, Case Series.