Assessment of the risk factors determining the prognosis of major and minor limb amputations in patients with diabetic foot ulcers.

BACKGROUND: Diabetes mellitus (DM) is a major global health problem, and its incidence is growing. Depending on this increase, the number of diabetes-related complications will also rise. OBJECTIVES: This study aimed to determine the risk factors associated with major and minor amputations resulting from diabetes. MATERIAL AND METHODS: Patients diagnosed with diabetic foot complications (n = 371) and hospitalized between January 2019 and March 2020 were retrospectively evaluated using information obtained from the database of Diabetic Foot Wound Clinic. Examination of the data identified 165 patients for inclusion in the study, who were stratified into major amputation (group 1, n = 32), minor amputation (group 2, n = 66) and non-amputation (group 3, n = 67) groups. RESULTS: Of the 32 patients who underwent major amputations, 84% had a below-knee amputation, 13% had an above-knee amputation and 3% had knee disarticulation. At the same time, 73% of 66 patients who underwent minor amputation had a single-finger amputation, 17% had a multiple-finger amputation, 8% had a transmetatarsal amputation, and 2% had Lisfranc amputation. Laboratory results showed high acute phase protein and low albumin (ALB) levels in patients from group 1 (p < 0.05). Although Staphylococcus aureus was found to be the most common infectious agent, Gram-negative pathogens were dominant (p < 0.05). Also, there was a significant cost difference between the groups (p < 0.05). Furthermore, those aged over 65 had a high Wagner score, high Charlson Comorbidity Index (CCI), long diabetic foot ulcer (DFU) duration, and high white blood cell (WBC) count, all of which were risk factors for major amputation (p < 0.05). CONCLUSIONS: This study demonstrated an increased Wagner staging and incidence of peripheral neuropathy (PN) and peripheral arterial disease (PAD) in major amputation patients. In addition, the rate of distal vessel involvement was high in major amputation patients, with elevated acute phase proteins and low ALB levels crucial in laboratory findings.

Effects of anterior cruciate ligament rupture and reconstruction on sexual activity of male patients.

OBJECTIVES: This study aims to investigate the impact of anterior cruciate ligament (ACL) injury and its reconstruction on men's sexual functions. PATIENTS AND METHODS: Between February 2016 and November 2019, a total of 27 sexually active male patients (mean age: 33.7±4.3 years; range, 26 to 40 years) who were operated for ACL injury at least six months after trauma were retrospectively analyzed. Erectile function was assessed using the International Index of Erectile Function questionnaire (IIEF) and knee function was evaluated by using the International Knee Documentation Committee (IKDC) Scoring System, Lysholm Knee Scoring Scale, and Tegner Activity Score. Sexual and functional questionnaires were applied to evaluate three different periods retrospectively. These periods were as follows: the period before an ACL injury (Period I); the period in which the patient suffered from an ACL injury, but not operated (Period II), and the period after the ACL reconstruction (Period III). RESULTS: There was a statistically significant difference in the comparison of knee function scores according to three different periods. Sexual function scores were significantly different between Periods I and II, and between Periods I and III. However, although the IIEF value was higher in Period III than in Period II, no statistically significant difference was observed. A moderate correlation was found between the sexual functional scores of IIEF and IKDC scores. CONCLUSION: Our study results suggest that ACL injury affects sexual functions adversely. The change in sexual functions after ACL surgery depends on the success of surgery. While deciding on the treatment of ACL injury, the patient's sexual life should be questioned along with his expectations.

Mid-Term Results of the First Dorsal Metacarpal Artery Flap for Thumb Defects.

Background: The thumb plays an important role in the function of the hand. Sensate reconstruction of the pulp is important in restoring function to the thumb. The aim of this study is to present outcomes of a sensate islanded first dorsal metacarpal artery (FDMA) flap used for the reconstruction of skin defects of the thumb. Methods: Patients who had a FDMA flap reconstruction of thumb pulp defects in the orthopaedics and traumatology clinic of affiliated hospital were included in the study. This included eight thumbs of eight patients. The range of motion, sensation and cosmetic satisfaction in the donor and recipient areas were evaluated at a minimum of 2-year follow-up. Results: There were no partial or complete flap failures. The mean static 2-point discrimination was 15 mm and the mean Semmes-Weinstein monofilament test score was 3.93. Cortical re-orientation was observed in 65% of patients. Near normal range of motion and Kapandji scores were regained in all patients. Conclusions: Excellent motion and sensory outcomes were obtained following the FDMA flap reconstruction of thumb pulp defects. The donor morbidity of the flap is minimal, and this flap can be considered as one of the primary options for reconstruction of thumb pulp defects. Level of Evidence: Level V (Therapeutic).

The Influence of Component Rotational Malalignment on Early Clinical Outcomes in Total Knee Arthroplasty.

Background The most important cause of patient dissatisfaction following total knee arthroplasty (TKA) is pain. Component rotation is an important factor in the clinical success of TKA. This study aims to determine component rotational errors in patients with mobile- and fixed-bearing polyethylene inserts after TKA and also to evaluate the effect of possible malrotations on clinical outcomes. Methods Seventy-five knees from sixty-six patients who underwent TKA were evaluated retrospectively. The patients were divided into two groups according to whether they received a mobile-bearing polyethylene insert (group 1, n = 48) or a fixed-bearing polyethylene insert (group 2, n = 27). The Hospital for Special Surgery (HSS) score, the Western Ontario and McMaster Universities Arthritis Index (WOMAC), the Lysholm Knee Scoring Scale, and the Oxford Knee Score were used for the clinical evaluation of the patients. The rotational state of the components was evaluated by computed tomography. Results The HSS, WOMAC, Lysholm, and Oxford clinical scores were not significant between the two groups (p > 0.05). The effect of femoral versus tibial component rotational deviation on clinical scores was not significant between the two groups (p > 0.05). Component rotational differences did not have a significant effect on the degree of knee flexion and extension between groups (p > 0.05). When the combined rotations of the components were compared with the clinical scores of function, no significant difference was detected between groups (p > 0.05). In addition, no significant difference between the operated sides of the patients and the combined component internal rotations was found (p > 0.05). Conclusion Although component rotation is an important factor in the clinical success of TKA, the current study did not find a clear association between the clinical results after TKA and the internal rotation of components. Component internal rotation alone is not an important predisposing factor for pain development after TKA. We believe that this may be attributed to the significant effects of patient expectation, which is often ignored, on clinical scores.

Failure of Major Upper Extremity Replantation Due to COVID-19-Related Arterial Thrombosis.

Coronavirus disease of 2019 (COVID-19), caused by the new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that emerged in Wuhan, was declared a pandemic by the World Health Organization. COVID-19 has many different clinical manifestations. One of them is arterial hypercoagulopathy. Although its mechanism is not fully explained, acute thrombosis and thromboembolism can be seen in patients. In this study, we present a case who was amputated due to the development of arterial thrombosis on the 10th day following infection with coronavirus, despite successful replantation after traumatic above-elbow amputation. After replantation on the seventh day, it was learned that the patient's husband was positive for COVID-19 and had come to visit the patient. For this reason, we performed reverse transcription polymerase chain reaction (RT-PCR) to confirm the patient's COVID-19 status. We found that the patient, who was asymptomatic, was positive by RT-PCR for COVID-19. On the 10th day after the operation, it was observed that the blood circulation of the replanted extremity was impaired, although it had been perfect until that day. Emergency embolectomy and vascular reanastomosis were planned for the patient. Although we generally observe thrombosis at an end-to-end anastomosis site, massive axillary arterial thrombosis was detected at the proximal end of the vascular anastomosis. Upon development of tachycardia, hypotension, and metabolic acidosis after embolectomy and vascular reanastomosis, the decision was made to amputate the replanted limb to reduce the risk of life-threatening complications. To our knowledge, this is the first such COVID-19-related complication on upper extremity replantation in the literature.

Catastrophic failure and metallosis of the acetabular component in total hip arthroplasty.

BACKGROUND: To evaluate the clinical features and results of the revision total hip arthroplasties (THA) in patients with catastrophic failures and metallosis. METHODS: Fifteen hips of 14 patients with catastrophic failure and metallosis in hip arthroplasties were evaluated. They were followed for at least 4.2 years after the revision THA. Clinical evaluation was performed using Harris hip score. Osteolysis, loosening or presence of metallosis was evaluated with standard radiographs. Metallosis was evaluated intraoperatively according to the metallosis severity classification. RESULTS: The mean time from failure until revision surgery was 9.4 years. It was observed that in the primary THA, metal-on-ceramic (MoC), ceramic-on-ceramic (CoC) and metal-on-conventional polyethylene (MoCPE) bearings were used in 1, 3 and 11 hips, respectively. Grade III metallosis was observed in all patients during revision surgeries. The mean Harris hip score increased from 55 points before revision THA to 75 points at the final follow-up. In revision arthroplasty, MoCPE and CoC bearings were used in 13 and 2 hips, respectively. The femoral stem was replaced in 5 hips. All acetabular cups, except that of one hip, were revised. CONCLUSIONS: Revisions of THAs with catastrophic failures and metallosis are quite challenging. Routine follow-up of arthroplasty patients is beneficial to examine for osteolysis, loosening, and asymmetric wear.

A multicenter intertrochanteric fracture study in the elderly: Hemiarthroplasty versus proximal femoral nailing.

OBJECTIVES: This study aims to compare the clinical and functional results of intertrochanteric femoral fractures treated with bipolar hemiarthroplasty (BHA) or proximal femoral nailing (PFN) in elderly patients. PATIENTS AND METHODS: This multicenter, prospectively followed-up, retrospectively compared cohort-type study included 308 patients (81 males, 227 females; mean age 78.4±7.2 years; range, 65 to 95 years) who were treated with BHA or PFN for intertrochanteric fractures by five orthopedic surgeons in four provinces and seven clinics between January 2014 and May 2018. Clinical follow-up was performed at third week, third and sixth months, and at the end of the first and second years. The American Society of Anesthesiologists for preoperative status, Singh index for bone quality, and Harris Hip Score (HHS) for functional outcomes were evaluated. RESULTS: While 156 patients (38 males, 118 females; mean age 77.7±5.9) were treated with BHA, 152 patients (43 males, 109 females; mean age 79±6.1) were treated with PFN. While there was no significant difference between the two groups in terms of total HHS, a significant difference was found in the sub-parameters (p<0.001). Good and excellent results were found in 78.2% of BHA and 86.2% of PFN patients. Mortality rates were similar at the end of two years (14% and 13.6%, respectively). CONCLUSION: In general, clinical and functional outcomes of BHA and PFN are similar. The rates of pulmonary embolism and deep vein thrombosis are significantly higher in BHA. However, BHA is advantageous in terms of operation time and early weight bearing compared to PFN.

Midterm Results of Tension Band Wiring Technique for Acute Rockwood Type III Acromioclavicular Joint Dislocation.

Background The aim of this study was to evaluate the clinical and radiological results of patients with acute type III Rockwood acromioclavicular joint (ACJ) dislocation treated surgically by employing tension band wiring. Methods The study included 24 patients with traumatic type III ACJ dislocations according to the Rockwood classification. The clinical and radiological outcomes of patients were assessed at the final follow-up visit. Implant failure and reduction loss were assessed using radiographs, whereas the Constant-Murley scoring system was used to assess the patients clinically. Results The mean follow-up period was 3.5 ± 1.3 years (range: 1-6 years). The mean age of the patients was 41.8 ± 11.7 years (range: 19-64 years) and the mean length of hospital stay was 2.3 days (range: 1-6 days). The fixation material was removed postoperatively at an average of 7.2 ± 9.9 months (range: 3-40 months). At the end of the follow-up period, the mean Constant-Murley score was 72.5 ± 12.8 (range: 50-90). The ACJ reduction was stable in 13 (54.2%) patients. Residual subluxation was detected in 11 (45.8%) patients. Distal clavicular osteolysis was noted in six (25%) patients. Acromioclavicular osteoarthritis was detected in five (20.8%) operated shoulders on follow-up radiographs. During the follow-up, Kirschner-wire migration and breakage occurred in four (16.6%) and seven (29.1%) patients, respectively. Conclusions This study showed that surgical treatment with the tension band wiring method provided functionally satisfactory results even if complications developed because of the presence of implants. Independent of age, we can recommend it as the primary treatment method for patients who do not have very high expectations regarding their shoulder function. Additionally, we think that reducing the duration of implant retention will reduce the incidence of complications.

The Long-Term Outcomes Following the Application of Intralesional Epidermal Growth Factor in Patients With Diabetic Foot Ulcers.

Epidermal growth factor is used as an adjuvant to close the wound in addition to standard care in diabetic foot ulcers. This study aimed to investigate the long-term outcomes after intralesional epidermal growth factor injections in the treatment of diabetic foot ulcers. Thirty-six feet of 34 patients (n = 34) with diabetic foot ulcers were included. Patient demographics, Wagner classifications, recurrence and amputation rates, Foot Function Index, Short Form 36, and American Academy of Orthopedic Surgeons Foot and Ankle Module scores were evaluated at the final follow-up examination. The mean age was 61.000 ± 13.743 years. The mean duration of wounds was 240.200 ± 146.385 days. A mean of 18.125 ± 4.494 (range 9 to 24) doses were applied. Wound closure was achieved in 33 of the 36 (91.7%) lesions. A complete response (granulation tissue >75% or wound closure) was observed in 29 (87.9%) lesions. The mean time to wound closure was 52.08 ± 10.65 (range 25 to 72) days. At the 5-year follow-up, 4 patients were lost to follow-up because of exitus owing to diabetic complications. Of the remaining 29 patients, 27 were ulcer free. In 2 patients (2 lesions, 6.9%) toe amputation was performed due to ischemic necrosis. The mean Foot Function Index, American Academy of Orthopedic Surgeons Foot and Ankle Core Scale, and AAOS Shoe Comfort Scale scores were 55.40 ± 12.15, 65.92 ± 17.56, and 56.42 ± 11.98, respectively. Complete wound healing and a low recurrence and amputation rates could be obtained with intralesional epidermal growth factor added to the standard treatment protocol.