Nevres Hürriyet Aydoğan

Early results of arthroscopic lateral retinacular release in patellofemoral osteoarthritis

The aim of this study was to define the postoperative course of middle-aged and elderly patients with patellar chondral lesions after lateral retinacular release and joint debridement. Thirty-five patients in their fifth to seventh decades with Grades 2-4 chondral lesions of the patellofemoral joint, with no patellar instability or severe malalignment, underwent lateral retinacular release and patellofemoral joint debridement by bipolar radiofrequency. Both VAS and WOMAC scores in all three lesion grades were significantly reduced postoperatively. The greatest decrease was observed in the first visit at 3 months, and the pain level continued at about the same level over the next 24 months without significant changes. There were no significant differences between the three lesion grades with respect to changes in VAS scores at each visit. Thermal lateral retinacular release improves the subjective condition of the patient by reducing pain, especially in the postoperative first 3 months.

Factors affecting the fracture healing in treatment of tibial shaft fractures with circular external fixator

This study aims to analyse the contribution of various risk factors for the delay of tibial shaft fractures treated by circular external fixator and predicting the high risk fractures for delayed union. 32 extraarticular tibial shaft fractures of 31 adult patients treated with circular external fixator were included. The patients were analysed according to age, energy of trauma, having an open fracture or not, AO classification, obliquity, use of supplementary fixation techniques in surgery, distance of fracture line to neighbouring rings, having a pin-track infection or not, reduction score, and smoking. There were eight delayed unions and two non-unions in our study. Consolidation time was significantly shorter (p=0.01) between the supplementary fixation group and the others. There was a significant difference in fracture healing time between pin-track-infected patients and the patients who did not have pin-track infection (p=0.037). In conclusion, our results indicate that non-union infection and not using supplementary fixation techniques are the major factors that delay the healing time. Supplementary fixation enhances the reduction rate and a low reduction score is related with the occurrence of a pin-track infection.

Three-point index in predicting redisplacement of extra-articular distal radial fractures in adults

INTRODUCTION In distal radial fractures in adults, factors affecting instability have been investigated in many studies in an effort to shorten the preoperative waiting period for the fractures requiring surgery. Numerous factors, aside from the alignment-related indices, have been searched to predict redisplacement. Unlike as in paediatric counterparts, the casting technique and casting-related indices have not been appropriately considered in adults. The aim of this study was to determine the impact of the various previously investigated factors in addition to casting technique-related indices such as three-point index, cast index, padding index and gap index, in predicting the risk of redisplacement of extra-articular distal radial fractures in adults and the presence of the ulnar deviation of the cast. PATIENTS AND METHODS Seventy-five patients over 18 years who were treated with a cast in our emergency department within 24h after a displaced distal radial fracture, were recruited into the study. Age, alignment-related indices, cast-related indices, extent of the ulnar deviation of the cast, having a non-anatomical reduction, co-existing ulnar fracture, dorsal comminution and obliquity of the fracture line were investigated. Casting technique according to three-point index, obliquity of the fracture line, degree of the ulnar deviation of the cast, and reduction accuracy were the significant factors affecting redisplacement. RESULTS The three-point index had a sensitivity of 95.8%, specificity of 96.1%, positive predictive value of 92%, and negative predictive value of 98% in predicting redisplacement. Logistic regression revealed that having an inadequate cast according to the three-point index (p<0.001), degree of obliquity of the fracture line (p=0.018), decreased ulnar deviation of the cast (p=0.002), and having a non-anatomical reduction (p=0.029) were the significant predictive factors in redisplacement. CONCLUSIONS Our results suggest that the casting technique plays a major role in the success of conservative treatment, which can best be examined with the three-point index. Ulnar deviation of the cast and fracture obliquity are the other dominant factors affecting redisplacement.

Treatment of Clubfoot with the Ponseti Method: Should We Begin Casting in the Newborn Period or Later?

The Ponseti method has become accepted worldwide as the treatment of choice for nonoperative management of clubfoot. However, there has been no research on whether casting should begin in the newborn period (< or = 30 days old) or later (> 30 days but < 1 year old) or on whether the length of the foot at the beginning of casting is predictive of the outcome of therapy. Therefore, we conducted an investigation to compare outcomes in patients started on casting therapy in the newborn period or later. Outcomes were based on Pirani and Diméglio scores. The study population was comprised of 40 clubfeet in 29 consecutive infants with no associated neuromuscular disease, who underwent Ponseti treatment. The median follow-up was 34 months (range, 20-47 months). Casting began in the newborn period on 26 feet of 18 patients (newborn group), and after 1 month of age on 14 feet of 11 patients (older infant group). Final Diméglio scores were significantly worse for the patients whose casts were applied in the newborn period, compared with those who had the first cast applied at a time >30 days postpartum (P = .04). Infants with feet > or =8 cm in length at the start of cast treatment had better final Diméglio scores than those with feet <8 cm. Our findings suggest that casting according to the Ponseti method should begin in infants older than 1 month of age, or with an involved foot > or =8 cm in length.

A Case of an Aneurysmal Bone Cyst of a Metatarsal: Review of the Differential Diagnosis and Treatment Options

UNLABELLED Aneurysmal bone cyst localized to the metatarsus, while not unheard of, is rather uncommon. The differential diagnosis for this lesion can be challenging, particularly in regard to the possibility of the presence of other giant cells containing tumors of bone, such as giant cell tumor, giant cell reparative granuloma, Browns tumor of hyperparathyroidism, and telangiectatic osteosarcoma. We report a case of an aneurysmal bone cyst localized to the third metatarsal in a 14-year-old girl who presented with limping, progressively worsening local pain, and swelling in her left foot. The differential diagnosis for her condition was extensive. Ultimately, an en bloc resection was undertaken and the defect was replaced with tricortical iliac autograft. Pathological analysis of the resected tissue was consistent with aneurysmal bone cyst. There was complete healing with no sign of recurrence 3 years after the surgery. LEVEL OF CLINICAL EVIDENCE 4.

Does the method of expression of venous blood affect ischaemia/reperfusion damage in tourniquet use? An experimental study on rabbits

The aim of this study was to compare the ischaemia and reperfusion phases of two tourniquet application models (Group 1: expressing the blood by a sterile rubber bandage and Group 2: elevation of the limb for several minutes) using an analysis of ischaemia/reperfusion parameters and blood pH. Sixteen New Zealand rabbits were used. Muscle samples were extracted from the triceps surae; at phase A (baseline: just before tourniquet application), phase B (ischaemia: 3h after tourniquet inflation) and phase C (2h after tourniquet deflation). Nitrite, nitrate, reduced glutathione, myeloperoxidase, malondyaldehyde were measured in the samples. Blood pH was also measured at each phase. Group 2 had significantly decreased nitrite (p=0.007) and nitrate (p=0.01) levels compared to Group 1 while passing from phase A to phase B. The pH decrease through the phases was significant within Group 1 (p=0.006) and was not significant within Group 2 (p=0.052). Lower levels of NO metabolites nitrate and nitrite, result from tourniquet use with incomplete venous blood expression by elevation. Also, with this technique severe acidosis is less likely to occur than when a tourniquet is used with expression of the venous blood by rubber bandage. These findings may help in the decision of which tourniquet technique is to be used for potentially long operations which may exceed 2h.

Fracture Risk Assessment Tool (FRAX®) Results Calculated With and Without Bone Mineral Density Values for the Evaluation of Fracture Risk in Postmenopausal Women With Osteopenia

The aim of this study was to evaluate the agreement between fracture risk predictions based on calculations made with and without bone mineral density (BMD) values using the Fracture Risk Assessment Tool (FRAX®) in Turkish postmenopausal women with osteopenia and to compare the treatment recommendations. This descriptive, cross-sectional study included postmenopausal women aged 50-79 yr with a diagnosis of osteoporosis who were not receiving any treatment. A questionnaire was administered to the participants face-to-face to obtain sociodemographic characteristics, medical history, and fracture history. Fracture risk was calculated with FRAX® separately with and without BMD. The study included 230 postmenopausal patients with osteopenia. The mean age of the patients was determined as 63.16 ± 7.59 yr, and the mean body mass index was 30.61 ± 5.02. The intraclass correlation coefficient values of the 10-yr major osteoporotic (MO) fracture and hip fracture score agreement with FRAX® with and without BMD were mean 0.486 and 0.462, respectively. The risk of MO fracture with an intervention threshold of ≥20 was determined in 227/230 patients (98.7%), and the risk of hip fracture with treatment recommendations of ≥3 was determined in 204/230 patients (88.7%). Treatment recommendations in patients with no fracture history and secondary osteoporosis were 100% for MO fracture and 94.7% (123/130) for hip fracture risk. The treatment recommendation rates of FRAX® with and without BMD were similar for the majority of postmenopausal women with osteopenia. The agreement between the values was of a moderate level. When patients with a fracture history and secondary osteoporosis were excluded, the agreement increased. Even though values with BMD are of basic importance for medical treatment in postmenopausal women, the use of measurements evaluating fracture risk, such as FRAX® without BMD, could be useful in postmenopausal women with osteopenia.

Agreement between the Turkey Guidelines and the Fracture Risk Assessment Tool®-based Intervention Threshold

Background The aim of this study was to evaluate the agreement between the fracture-risk assessment tool (FRAX®)-based intervention strategy in Turkey and the recommendations published in the Healthcare Practices Statement (HPS). Methods This descriptive cross-sectional study included individuals aged 40 to 90 years who were previously diagnosed as having osteoporosis but had not received any treatment. The intervention thresholds recommended by the National Osteoporosis Foundation for treatment were used. The criteria necessary for the start of administration of pharmacological agents in osteoporosis treatment were evaluated on the basis of the HPS guidelines. Results Of the 1,255 patients evaluated, 161 (12.8%) were male and 1,094 (87.2%) were female. In the evaluation, according to HPS, treatment was recommended for 783 patients (62.4%; HPS+) and not recommended for 472 (37.6%; HPS−). Of the 783 HPS+ patients, 391 (49.9%) were FRAX+, and of the 472 HPS− patients, 449 (95.1%) were FRAX−. A statistically significant difference was observed between the treatment recommendations of HPS and FRAX® (P<0.001). In the age group of 75 to 90 years, excellent agreement was found between the two strategies (Gwets agreement coefficient 1=0.94). As age increased, the agreement between the two treatment strategies also increased. Conclusions The FRAX® model has different treatment recommendation rates from the HPS. The agreement between the two is at a minimal level. However, as age increased, so did the agreement between the FRAX® and the HPS treatment recommendations. In the recommendation to start pharmacological treatment primarily based on age, non-medical interventions that preserve bone density should be evaluated.

Letter to the editor concerning “Intraoperative lateral wall fractures during Dynamic Hip Screw fixation for intertrochanteric fractures—Incidence, causative factors and clinical outcome”

We read with great interest the article by Pradeep et al. entitled, “Intraoperative lateral wall fractures during Dynamic Hip Screw fixation for intertrochanteric fractures—Incidence, causative factors and clinical outcome”. We congratulate the authors on this study emphasising the factors affecting the development of lateral femoral wall (LFW) fracture following dynamic hip screw (DHS) fixation of intertrochanteric femur fractures [1]. However, we would like to draw attention to some points related to factors which could affect the formation of this fracture during the application of DHS. Cephalomedullar nailing is the current treatment method for unstable intertrochanteric femoral fractures [2]. After DHS applications in these fractures, there are risks of mechanical failure such as shortening of the femoral neck, cut-out and back-up of the dynamic screw as early weight-bearing can change the load on the implant [3]. The implementation of a mobilisation protocol according to fracture type, time to mobilisation and bone quality can reduce this risk [2]. Therefore, the authors should state the physical therapy protocol applied and the follow-up intervals of the patients. Another feature of the DHS system is controlled fracture impaction. Reduction quality is another factor affecting this impaction so it would be useful for the authors to report the reduction quality. The authors reported that there was a significant relationship between the 34/135 (19.5%) patients where there was a lateral wall fracture during surgery and that 23 (68%) had a preoperative unstable fracture pattern and 11 (32%) had a stable fracture pattern (p < 0.001). While only 3 of these patients were in the 3A1 group, the remainder (73.5%) were 3A2 fractures. Following LFW fractures, medialization of distal fragments was seen in 22 patients of which <1/3 medialization was seen in 13 patients and >1/3 medialization was seen in 9 patients [1]. This is an expected result in these unstable fractures. The protective function of the lateral femoral wall should not only be evaluated with medialisation, but evaluation together with complications such as shortening in the extremity, non-union and collapse in the varus position which can subsequently develop will provide more information [3,4]. Evaluation of the role of LFW on re-operation is important [5]. To avoid all these complications in unstable fractures, it is recommended that cable or TSP plates are used for LFW reconstruction or an anti-rotation screw is applied to increase