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The aim of this study was to evaluate the possible effect of radiographic loosening on clinical and functional outcomes, while presenting the mid-term radiographic and functional outcomes of cemented, monopolar RHA applied to patients with comminuted radial head fractures. We performed a retrospective study by evaluating the records of patients who were diagnosed in a single center with radial head fractures between 2001 and 2013. Twenty-six patients with comminuted radial head fractures with a mean age of 48.9 and a mean follow-up time of 132.2 months were included. The radiographic evaluation was performed by assessing peri-prosthetic radiolucent lines around the stem to evaluate loosening, while the clinical evaluation was performed by utilizing elbow range of motion (ROM), Mayo elbow performance score (MEPS), Oxford elbow score (OES) and quick-DASH scores. 13 patients (Group 1) with peri-prosthetic stem lucency were defined as radiographic loosening (50%), while the remaining 13 patients (Group 2) were not detected to have stem lucency. One patient in group 1 also had concomitant pain and underwent removal of the prosthesis, while 12 patients (92.3%) remained pain-free. On the latest follow-up visit, there was no significant difference between the groups regarding ROM, MEPS, OES and quick-DASH scores. Within ten years following surgery, half of the patients with radial head prostheses were noted to show radiographic signs of loosening which did not have any major negative effect in terms of clinical-functional outcomes and quality of life, except requiring the removal of the implant in one patient. Level III.

Objective: the present study aimed to compare the isometric strength and endurance of shoulder abduction and internal and external rotation between operated shoulders and nonoperated, contralateral shoulders of patients who underwent reverse shoulder replacement due to unilateral rotator cuff tear arthropathy. Patients and methods: with a diagnosis of cuff tear arthropathy, 41 consecutive patients (mean age of 70.8 years; age range, 57 to 84; 36 females, 5 males) who underwent unilateral reverse shoulder arthroplasty were reviewed based on functional and radiological data. In all cases, cuff tear arthropathy was unilateral and contralateral shoulder was asymptomatic, with normal shoulder function. The average length of follow-up was 34 months (range of 12–67). To assess patients' functional level, the Constant score and the Disabilities of the Arm, Shoulder, and Hand (the Quick-DASH) outcome measure were used preoperatively and at the final examination. The primary outcomes of the present study were measurement of isokinetic strength and endurance of shoulder abduction and internal and external rotation using an isokinetic evaluator. Results: patients exhibited marked improvement in functional level as reflected by a significant increase in the mean Constant score from 38 preoperatively to 65 at the final follow-up (p = 0.03). The functional improvement was supported by a decrease in the mean Quick-DASH from 64 preoperatively to 26 at the final follow-up (p = 0.018). In the comparison of the isokinetic strength and endurance of shoulder abduction, no statistical difference was observed between operated shoulders and contralateral shoulders (p > 0.05). However; the strength and endurance of internal and external rotation were lower in operated shoulders than in contralateral shoulders (p < 0.05). Similarly, there was no statistically significant difference in comparisons of the durability of abduction (p > 0.05); however, the durability of internal and external rotation were significantly lower in operated shoulders (p < 0.05). Conclusion: in terms of durability and strength of abduction, similar results with the unaffected shoulder may be accomplished; nonetheless, the surgeon should be aware that durability and strength of rotation would be weak. Level of evidence: Level III, Therapeutic Study., NA

Scapular morphology is an extrinsic factor playing role in rotator cuff tear (RCT) etiology. The objective of this study was to evaluate the relationship between critical shoulder angle (CSA) and acromion index (AI) with partial-bursal side and full thickness RCT and the size of the RCT.The hypothesis was that CSA and AI would be greater in partial bursal-side RCT and full-thickness RCT patients and would increase with the size of the RCT.This retrospective study assessed 218 patients who had standard shoulder radiographs and magnetic resonance imaging. Patients were divided into three groups: intact rotator cuff (68), partial bursal-side RCT (34) and full-thickness RCT (116). In the second part, full-thickness RCT patients were divided into four groups according to RCT size; small (1cm), medium (1-3cm), large (3-5cm) and massive (5cm). AI and CSA measurements were evaluated from radiographs.The mean CSA was 32.8̊ in control group, 34.3̊ in partial group and 36.9̊ in full-thickness group. The mean AI was 0.66, 0.68 and 0.72 respectively. Significant difference was found in AI and CSA between full thickness RCT and intact RC group (p0.01), and partial RCT and full thickness RCT group (p0.05) in paired comparisons. In full thickness RCT size groups the mean CSA was 34.2̊, 36.4̊, 39.0̊ and 40.8̊ and mean AI was 0.70, 0.71, 0.73 and 0.79 respectively. Significant difference was found between small-large, small-massive, medium-massive groups for CSA in paired comparisons and between small-massive, medium-massive groups for AI.CSA and AI were significantly greater in full-thickness RCT patients and the size of the RCT increased with CSA and AI. The greater CSA and AI could be predictors for larger RCT.III; Cross-Sectional Design; Prognosis Study.

Objective The aim of this study was to determine the effect of intravenous (IV) tranexamic acid (TRX) use on visual clarity during arthroscopic rotator cuff repair. Methods This prospective, randomized, double-blinded, placebo-controlled study was conducted in patients scheduled for an arthroscopic rotator cuff repair. In total, 60 patients were randomly distributed into two groups: control (28 patients: 11 male, 17 female; mean age=53 years, age range=19-65) and TRX (32 patients: 15 male, 17 female; mean age=50, age range=18-69). In the TRX group, the arthroscopy was performed through the bolus IV administration of 10 mg/kg TRX in 100 ml isotonic saline solution. In the control group, the arthroscopy was performed through the bolus IV administration of 100 ml isotonic saline solution. In both the groups, the IV administration was carried out after the induction of anesthesia. At the end of each procedure, the surgeon rated the visual clarity on a scale from 1 to 10. In addition, operation time (minutes), irrigation amount used in operation (lt), and the need of pressure increase because of bleeding were recorded. Results No adverse effects were seen during the study period. Visual clarity in TRX group was significantly better than the control group (the mean visual clarity scores=8.1/10 (range=7-10) vs 7/10 (range=5-9); p=0.018). The amount of solution was significantly less in the TRX group (10.2 lt (range=3.5-21)) than in the control group (15.8 lt (range=5.8-27); p=0.007, post-hoc power=95.7%), although the operation time was slightly longer in the TRX group (106 minutes (range=50-210)) than in the control group (99 minutes (range=45-165); p=0.24). Moreover, the need for the increase in pressure owing to bleeding was found significantly less in the TRX group (5.8 times (range=(0-9)) than in the control group (9.6 times (range=0-13); p=0.04, post-hoc power=94.5%). Conclusion Preoperative IV TRX administration seems to be effective in improving visual clarity and reducing the need for high pressure and the amount of irrigation fluid during the arthroscopic rotator cuff repair. Level of evidence Level II, Therapeutic study.

Context: ideal rehabilitation method following arthroscopic capsulolabral repair surgery for anterior shoulder instability has not been proven yet. Although rapid or slow protocols were compared previously, home- or hospital-based protocols were not questioned before. Objective: the aim of this prospective unrandomized controlled clinical trial is to compare the clinical outcomes of home-based and hospital-based rehabilitation programs following arthroscopic Bankart repair. Design: non-randomized controlled trial. Setting: orthopedics and physical therapy units of a single institution. Patients: fifty-four patients (49 males and 5 females) with an average age of 30.5 (9.1) years, who underwent arthroscopic capsulolabral repair and met the inclusion criteria, with at least 1-year follow-up were allocated into 2 groups: home-based (n = 33) and hospital-based (n = 21) groups. Interventions: both groups received identical rehabilitation programs. Patients in the home-based group were called for follow-up every 3 weeks. Patients in the hospital-based group admitted for therapy every other day for a total of 6 to 8 weeks. Both groups were followed identically after the eighth week and the rehabilitation program continued for 6 months. Main Outcome Measures: Clinical outcomes were assessed using Disabilities of Arm Shoulder Hand, Constant, and Rowe scores. Mann-Whitney U test was used to compare the results in both groups. Wilcoxon test was used for determining the progress in each group. Results: groups were age and gender matched (P =.61, P =.69). Average number of treatment sessions was 13.8 (7.3) for patients in the hospital-based group. Preoperative Disabilities of Arm Shoulder Hand (27.46 [11.81] vs 32.53 [16.42], P =.22), Constant (58.23 [14.23] vs 54.17 [10.46], P =.13), and Rowe (51.72 [15.36] vs 43.81 [19.16], P =.12) scores were similar between groups. Postoperative scores at sixth month were significantly improved in each group (P =.001, P =.001, and P =.001). No significant difference was observed between 2 groups regarding clinical scores in any time point. Conclusions: we have, therefore, concluded that a controlled home-based exercise program is as effective as hospital-based rehabilitation following arthroscopic capsulolabral repair for anterior shoulder instability., NA

Aims The present study aimed to investigate the long-term functional results of scapulothoracic fusion using multifilament cables in patients with facioscapulohumeral dystrophy (FSHD) to identify if the early improvement from this intervention is maintained. Patients and Methods We retrospectively investigated the long-term outcomes of 13 patients with FSHD (18 shoulders) in whom scapulothoracic fusion using multifilament cables was performed between 2004 and 2007. These patients have previously been reported at a mean of 35.5 months (24 to 87). There were eight men and five women with a mean age of 26 years. Their mean length of follow-up of our current study was 128 months (94 to 185). To evaluate long-term functional results, the range of shoulder flexion and abduction, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores were analyzed with a comparison of preoperatively, interim and at the final outcomes. The fusion was examined radiographically in all. Results The complication rate was 33% (six of 18 scapulothoracic fusions) in 13 patients, which comprised failure of fusion in four shoulders (four patients) all occurring within the first year postoperatively. In two shoulders (one patient) wound problems arose due to attribution from the cables which required shortening but the fusion developed satisfactorily. At the final examination, the mean QuickDASH score and range of movement significantly improved in all but one patient (p < 0.001, p < 0.001 and p < 0.001). In the comparison of 13 patients’ mid- and long-term results, the mean QuickDASH score decreased from 9.8 (sd 6.7; 3 to 26) in the third year to 9.1 (sd 5.6; 3 to 22) in the tenth year (p = 0.7); the mean range of shoulder flexion and abduction decreased from 129° (sd 22°; 90° to 160°) and 124° (sd 12; 100° to 150°) at the mid-term to 103° (sd 12°; 80° to 120°) and 101° (sd 8°; 80° to 120°) at the long-term, respectively (p = 0.78 and p = 0.65). Conclusion Scapulothoracic fusion using a multiple cabling method can confer a considerable improvement in clinical and functional outcomes for most patients with FSHD after a long follow-up period. The technique requires careful execution to avoid complications. Cite this article: Bone Joint J 2018;100-B:953–6.

Objective: This study aimed to present middle-term functional and radiological outcomes of the transfer of the lesser tuberosity in the management of reverse Hill-Sachs lesions following posterior dislocations of the shoulder. Patients and methods: With a diagnosis of neglected posterior shoulder dislocation (8 locked, 5 recurrent), 13 male patients (age range: 28-72; mean age: 39.3 years) who underwent the transfer of the lesser tuberosity due to reverse Hill-Sachs lesions, were retrospectively reviewed based on functional and radiological data. The etiologies were: epilepsy in 9 patients, a traffic accident in 2 patients, and fall in 2 patients. To assess the patients' functional level, American Shoulder and Elbow Surgeons (ASES) and Constant Scores were used, and the patients' range of motion at the last follow-up was measured. To evaluate the development of arthrosis, the final follow-up control plain radiographs were examined. The average size of the defects calculated from the axial computed tomography sets was 27% (range: 20%-40%). Results: The average length of follow-up was 30 months (range: 12-67 months). At the last follow-up visit, the main ASES and Constant Scores were 78 and 85, respectively, and the average degrees of flexion, abduction, and external rotation were 163,151, and 70 respectively. The concentric reduction was observed postoperatively. Conclusion: McLaughlin procedure appears to be a safe and effective method in the treatment of neglected posterior shoulder dislocations with reverse Hill-Sachs lesion. Level of Evidence: Level IV, Therapeutic study. (C) 2017 Turkish Association of Orthopaedics and Traumatology., NA

Objectives: In intraarticular distal humerus fractures, internal fixation with double plates is the gold standard treatment. However the optimal plate configuration is not clear in the literature. The aim of this study was to compare the biomechanical stability of the parallel and the orthogonal anatomical locking plating systems in intraarticular distal humerus fractures in artificial humerus models. Methods: Intraarticular distal humerus fracture (AO13-C2) with 5 mm metaphyseal defect was created in sixteen artificial humeral models. Models were fixed with either orthogonal or parallel plating systems with locking screws (Acumed elbow plating systems). Both systems were tested for their stiffness with loads in axial compression, varus, valgus, anterior and posterior bending. Then plastic deformation after cyclic loading in posterior bending and load to failure in posterior bending were tested. The failure mechanisms of all the samples were observed. Results: Stiffness values in every direction were not significantly different among the orthogonal and the parallel plating groups. There was no statistical difference between the two groups in plastic deformation values (0.31 mm-0.29 mm) and load to failure tests in posterior bending (372.4 N-379.7 N). In the orthogonal plating system most of the failures occurred due to the proximal shaft fracture, whereas in the parallel plating system failure occurred due to the shift of the most distal screw in proximal fragment. Conclusion: Our study showed that both plating systems had similar biomechanical stabilities when anatomic plates with distal locking screws were used in intraarticular distal humerus fractures in artificial humerus models. (C) 2016 Turkish Association of Orthopaedics and Traumatology., NA

BACKGROUND Facioscapulohumeral dystrophy (FSHD) is an autosomal-dominant myopathy characterized by facial and shoulder girdle muscle weakness with scapular winging. Scapulothoracic arthrodesis is a successful treatment approach for patients with

Objective: heterotopic ossification (HO) is a common cause of elbow stiffness following surgical treatment of elbow trauma. In this study, our aim was to evaluate the mid-term functional outcomes of open surgical procedures for HO. Methods: in this retrospective study approved by the institutional review board (IRB), all patients who were diagnosed as having stiff elbow due to HO and underwent surgical resection at a single institution from 2006 to 2013 were included. Intrinsic (inside the joint) pathologies were excluded. Range of motion (ROM) in sagittal and coronal planes, complications, functional scores such as Quick Disabilities of the Arm, Shoulder and Hand Score (Q-DASH), and Mayo Elbow Performance Score (MEPS) were evaluated before and after surgery. Results: there were 19 patients (16 males, 3 females) with a mean age of 38.6 (range 15-69) years. At an average follow-up of 36 +/- 8 months, the mean flexion-extension arc was improved from 27.4 degrees to 99.2 degrees (p, NA

Introduction The purpose of this study is to investigate the incidence of os acromiale in patients who had reverse shoulder arthroplasty (RSA) for rotator cuff tear arthropathy and the effect of presence of os acromiale on the functional results. Hypothesis We hypothesize than in the presence of os acromiale, the contraction strength of the deltoid would decrease due to the dynamic downward depression of the bony fragment leading to less favorable clinical results. Material and method A total 46 patients with a mean age of 70.8 who had RSA and a minimum follow-up of 24 months were included in this study. Preoperative radiographs, computerized tomography scans and magnetic resonance images were examined to determine the presence of os acromiale. Results A total of 10 patients out of 46 (22%) with os acromiale, all of which were of mesoacromion type, were followed up for 59.7 months. While both groups had significant improvements in Constant, Q-DASH and VAS scores compared to their preoperative status, a significant difference between the groups could not be found. The radiological evaluation showed that the average acromiohumeral distance significantly increased postoperatively in both groups. The acromiohumeral distance was significantly shorter in patients with os acromiale. Discussion While the presence of os acromiale does not have an adverse effect on the clinical results of the RSA, the loose fragment can migrate distally in the postoperative period due to the tension in the deltoid. Level of evidence III, case-control study.

This study assessed the effect of the time interval from initial injury to surgery and the presence of associated fracture on functional outcomes after acute posterior elbow fracture dislocation. Twenty-six pediatric patients were evaluated with respect to operation time point (within 24 h vs. later) and associated fracture retrospectively. The Mayo Elbow Performance Index (MEPI) score was used to assess functional results. The MEPI score was 91 (80-100) in patients with one associated fracture and 83 (75-95) (P=0.02) in patients with more than one associated fracture. The MEPI score in patients treated within 24 h was 90.3 (75-95) and in those treated later than 24 h, it was 88.6 (75-100) (P=0.6). Treatment time (within 24 h vs. later) does not affect outcomes, but increasing numbers of associated injuries affect outcomes negatively. Level of study: Level IV case series.

Background: Latissimus dorsi (LD) and teres major (TM) tendon transfers are effective surgical procedures to improve shoulder abduction and external rotation for children with obstetrical brachial plexus palsy (OBPP). Open pectoralis major (PM) tendon Z-plasty and arthroscopic subscapularis (SS) release are 2 options for the release of internal rotation contractures to enhance muscle transfers. This study compared the functional results of LD and TM tendon transfers with open PM tendon Z-plasty or arthroscopic SS release. Methods: the study included 24 patients who underwent LD and TM tendon transfers for OBPP (9 arthroscopic SS release, 15 open PM tendon Z-plasty) with a mean follow-up of 41.33 months (range, 36-60 months) and 47.2 months (range, 36-60 months), respectively. Functional evaluation was made according to range of motion and Mallet scoring system. Results: shoulder abduction–external rotation degrees and scores in all sections of the Mallet scoring system significantly increased in both groups (P, NA

Distal radius fractures are the most common fractures, accounting for 17% of fractures in the elderly population. Its treatment is challenging because of accompanying osteoporosis in this population. After the advantages of locking plates in osteoporotic bone stabilization were recognized, they became widely used as the treatment of choice in distal fractures of the radius. In low-energy fractures with no comminution, volar locking plate osteosynthesis is the current gold standard because it enables stable osteosynthesis and early joint mobilization. However, in high-energy fractures with many fragments, it is almost impossible to provide anatomic repositioning using open approaches. In such cases, fixation without opening the fracture and repositioning of fracture fragments by ligamentotaxis make the external fixator a feasible option. In this chapter, techniques and functional outcomes of external fixators in fragmented intra-articular radius distal fractures will be discussed in view of the current literature.

Introduction Recurrent haemarthrosis in haemophilic patients result with arthropathy of the radiocapitellar joint and blockage of the forearm rotation. Aim The aim of this study is to evaluate the mid-term results of radial head excision with partial synovectomy in severe haemophilic patients retrospectively. Methods Persistent pain and decreased forearm rotation were the main indications for radial head excision. Between 2002 and 2013, radial head excisions were performed for 14 elbows of 14 patients. Eleven patients were haemophilia A, whereas two patients were haemophilia B patients and the remaining one had von Willebrand (Type 3) disease. The mean age of the patients was 29 at the time of the surgery. The mean follow-up was 51 (12–155) months. VAS (visual analogue score) for pain, forearm rotation, qDASH and MEPS (Mayo Elbow Performance Score) were used as the primary outcome parameters. Results The mean VAS decreased significantly from 6.5 preoperatively to 2.2 at the final follow-up (P = 0.0003). The mean forearm rotation increased from 40° to 115° respectively (P = 0.0007). In two patients, efficacious rotation increase was not achieved due to distal radioulnar joint problems. The mean qDASH score and MEPS were 18.1 and 87.5 at the latest follow-up, respectively, where four patients had excellent and 10 patients had good results. Conclusions Radial head excision is a safe and effective procedure for haemophiliac patients with radiocapitellar arthropathy and decreased forearm rotation. Distal radioulnar joint should be evaluated preoperatively which may impair the results.

Only a few randomised, controlled studies have compared different non-operative methods of treatment of mid-shaft fractures of the clavicle.In this prospective, randomised controlled study of 60 participants (mean age 31.6 years; 15 to 75) we compared the broad arm sling with the figure of eight bandage for the treatment of mid-shaft clavicle fractures. Our outcome measures were pain, Constant and American Shoulder and Elbow Surgeons scores and radiological union.The mean visual analogue scale (VAS) pain score on the first day after treatment was significantly higher (VAS 1 6.8; 4 to 9) in the figure of eight bandage group than the broad arm sling group (VAS 1 5.6; 3 to 8, p = 0.034). A mean shortening of 9 mm (3 to 17) was measured in the figure of eight bandage group, versus 7.5 mm (0 to 24) in the broad arm sling group (p = 0.30).The application of the figure of eight bandage is more difficult than of the broad arm sling, and patients experience more pain during the first day when treated with this option. We suggest the broad arm sling is preferable because of the reduction of early pain and ease of application.Cite this article: Bone Joint J 2015;97-B:1562–5.

Infection after open fractures is a common complication. Treatment options for infections developed after intramedullary nailing surgery remain a topic of controversy. We therefore used a rat fracture model to evaluate the effects of infection on osseous union when the implant was maintained.In a rat model, (1) does infection alter callus strength; (2) does infection alter the radiographic appearance of callus; and (3) does infection alter the histological properties of callus?An open femoral fracture was created and fixed with an intramedullary Kirschner wire in 72 adult male Sprague-Dawley rats, which were divided into two study groups. In the infection group, the fracture site was contaminated with Staphylococcus aureus (36 animals), whereas in the control group, there was no bacterial contamination (36 animals). No antibiotics were used either for prophylaxis or for treatment. We performed biomechanical (maximum torque causing failure and stiffness), radiographic (Lane and Sandhu scoring for callus formation), and histologic (scoring for callus maturity) assessments at 3 and 6 weeks. The number of bacteria colonies on the femur, wire, and soft tissue inside knee were compared to validate that we successfully created an infection model. The number of bacteria colonies in the soft tissue inside the knee was higher in the infection group after 6 weeks than after the third week, demonstrating the presence of locally aggressive infection.Infection decreased callus strength at 6 weeks. Torque to failure (299.07 ± 65.53 Nmm versus 107.20 ± 88.81, mean difference with 95% confidence interval, 192 [43-340]; p = 0.007) and stiffness at 6 weeks (11.28 ± 2.67 Nmm versus 2.03 ± 1.68, mean difference with 95% confidence interval, 9 [3-16]; p = 0.004) both were greater in the control group than in the group with infection. Radiographic analysis at 6 weeks demonstrated the fracture line was less distinct (Lane and Sandhu score of 2-3) in the infection group and complete union was observed (Lane and Sandhu score of 3-4) in the control group (p = 0.001). Semiquantitative histology scores were not different between the noninfected controls and the rats with infection (score 10 versus 9).Retaining an implant in the presence of an underlying infection without antibiotic treatment leads to weaker callus and impedes callus maturation compared with noninfected controls in a rat model. Future studies might evaluate whether antibiotic treatment would modify this result.This model sets the stage for further investigations that might study the influence of different interventions on fracture healing in implant-associated osteomyelitis. Future observational studies might also evaluate the histological properties of callus in patients with osteomyelitis.

Fixations of fragments are the main aim of orthopedic trauma surgery. Although wires, screws, and plates are the popular fixation materials, sutures also have an important role [1, 2]. Most surgeons thought that hardware have more strength at the fixation side than sutures. We can easily say that it is true for large and messy fragments. But if the fragments are comminuted, osteoporotic, and fragile, hard fixation materials may give harm to the fracture sites and makes the procedure more complicated [3, 4]. Specially, fixations with sutures are useful for the treatment of fractures with tendon or ligament avulsion. At this time use of sutures could be an option for the fixation, which can give less harm to the small and fragile fracture ends. By using sutures as fixation material, the surgeons can use bone-tendon junction as a buttress side. Suture fixations can be used in various types of fractures. In this chapter, we describe major fields that suture fixation is the most favored type of fixation.

OBJECTIVES In arthroscopic rotator cuff surgery for postoperative analgesia opioids, nonsteroid analgesics, and local anesthetics can be used. This study aimed to compare the effectiveness, additional analgesic requirements, patients satisfaction, and complications of single-shot interscalene and supraclavicular blocks. METHODS After obtaining the ethics committee's approval and informed consent, 50 ASA I-II patients were randomized to either the interscalene (GISB) or supraclavicular (GSCB) group. Preoperatively, patients received an ultrasonography-guided block using 30 ml of 0.5% bupivacaine. In the postoperative period, morphine patient-controlled analgesia was administered as a 0.3-mg/h basal dose and 1-mg bolus dose, with a 20-min lockout time. Postoperative visual analog scale (VAS; 0-10 cm) scores of the patients were evaluated at 4, 8, 12, and 24 h postoperatively; additional analgesic requirements, adverse effects, and complications were recorded. Patient satisfaction (PS) scores were evaluated after 24 h. RESULTS VAS scores at 4 h were lower in the GSCB group than in the GISB group, and the VAS scores at 8, 12, and 24 h were lower in the GISB group than in the GSCB group, with no statistical significance. Additional analgesic requirements was 28% in the GISB group and 68% in the GSCB group (p < 0.05). Total morphine consumption was lower in the GISB group than in the GSCB group (18.95±9.2 mg vs. 30.6 ± 9.6 mg; p < 0.001). PS scores were higher in the GISB group than in the GSCB group (7.0±1.0 vs. 6.1±0.9; p < 0.01). Adverse effects and complication rates were similar in both the groups. In GISB group, seven patients (28%) had nausea/vomiting, whereas in the GSCB group, 12 patients (48%) had nausea/vomiting. This difference was statistically insignificant. CONCLUSION Supraclavicular block can be considered as an alternative to interscalene block for arthroscopic shoulder surgery.

Objective: The aim of this study was to evaluate the long-term radiological and functional results of distraction interposition arthroplasty using an Achilles tendon allograft.Methods: The study included 5 patients (3 females and 2 males; mean age: 31 years, range: 25 to 41 years) who underwent distraction interposition arthroplasty for stiff elbow and arthrosis due to intrinsic factors between 2001 and 2010. Interposition with fresh-frozen Achilles allograft and collateral ligament reconstruction were performed in all patients. Mean follow-up period was 87.6 (range: 40 to 131) months. Mean distraction time with an external fixator was 7 (range: 6 to 8) weeks. Elbow motion was allowed in the first postoperative day in all patients. Radiological evaluation was performed pre- and postoperatively. Elbow ROM, and the Mayo Elbow Performance Score (MEPS) and DASH scores were recorded for functional evaluation.Results: Mean preoperative flexion-extension range was 24° (range: 0° to 80°) and mean supination-pronation range was 15°. Two patients had elbow ankylosis in 90° and 60° of flexion at the preoperative examination. Mean postoperative flexion-extension range increased significantly to 81° (range: 50° to 110°) (p, Amaç: Bu çalışmada Aşil tendon allogrefti kullanılarak yapılan distraksiyon interpozisyon artroplastisinin uzun dönem radyolojik ve fonksiyonel sonuçlarının değerlendirilmesi amaçlandı.Çalışma planı: 2001-2010 yılları arasında intrensek kaynaklı dirsek sertliği ve artrozu nedeniyle distraksiyon interpozisyon artroplastisi uygulanan 5 hasta (3 kadın, 2 erkek; ortalama yaş: 31, dağılım: 25-41) çalışmaya alındı. Tüm hastalarda taze donmuş Aşil allogrefti ile interpozisyon ve kollateral bağ rekonstrüksiyonu uygulandı. Hastaların ortalama takip süresi 87.6 (dağılım: 40-131) ay idi. Eksternal fiksatörle distraksiyon ortalama 7 (dağılım: 6-8) hafta uygulandı. Tüm hastalara ameliyattan sonra 1. gün dirsek hareketine başlandı. Hastaların ameliyat öncesi ve sonrası radyolojik değerlendirmeleri yapıldı. Yine, ameliyat öncesi ve sonrası, hastaların dirsek eklemi hareket açıklığı, Mayo Dirsek Performans Skoru ve DASH skorları ölçülerek fonksiyonel değerlendirmeleri yapıldı.Bulgular: Hastaların ameliyat öncesi ortalama fleksiyon–ekstansiyon arkı 24° (dağılım: 0°-80°), supinasyon-pronasyon arkı 15° idi. İki hastanın ameliyat öncesi muayenesinde 90° ve 60° fleksiyonda dirsek ankilozu mevcuttu. Son kontrollerde ortalama fleksiyon-ekstansiyon arkının anlamlı olarak 81 dereceye (dağılım: 50°-110°) yükseldiği görüldü (p

Objective: The aim of this study was to clinically and radiologically evaluate patients treated with plate osteosynthesis with structural allografts for severely valgus-impacted fractures of the proximal humerus.Methods: The study included 10 patients (average age: 57 years; range: 34 to 77 years) with valgus-impacted Neer Type 4 proximal humerus fractures. Fractures were classified according to the Robinson classification. Patients were called for an up-to-date examination and evaluated radiologically and clinically with Constant and DASH scores.Results: Average follow-up period was 22.5±12.2 (range: 12 to 50) months. Average DASH score at the final follow-up was 7.6±4.5 (range: 2.5 to 16.7) and average Constant score was 87.7±4.4 (range: 83 to 94). None of the cases had early or late head collapse. There was no avascular necrosis. One early screw penetration was observed.Conclusion: Surgical treatment of valgus-impacted proximal humerus fractures achieved successful results. However, the cavity under the humeral head may lead to failure due to mechanical insufficiency. Plate osteosynthesis with structural allografts warrants initial mechanical support until union, thus avoiding complications related to head collapse., Amaç: Bu çalışmada yapısal allogreftlerle yapılan plak osteosentezi ile ileri derecede valgus impakte kırıkları üzerinde alınacak sonuçların klinik ve radyolojik açıdan değerlendirilmesi amaçlanmıştır.Çalışma planı: Valgus impakte Neer Tip 4 proksimal humerus kırığı tanısı alan ve ortalama yaşı 57 (dağılım: 34-77) olan 10 hasta çalışmaya dahil edilerek, kırıkları Robinson sınıflamasına göre sınıflandı. Hastalar güncel muayeneleri için çağrıldı; Constant ve DASH skorları ile klinik ve radyolojik olarak değerlendirildiler.Bulgular: Ortalama takip süresi 22.5±12.2 (dağılım: 12-50) ay olarak kaydedildi. Son kontrol sırasında ortalama DASH skoru 7.6±4.5 (dağılım: 2.5-16.7) ve Constant skoru 87.7±4.4 (dağılım: 83-94) olarak ölçüldü. Hastaların hiçbirinde erken ve geç baş çökmesi veya avasküler nekroz görülmedi. Bir hastada erken vida penetrasyonu saptandı.Çıkarımlar: Valgus impakte kırıkların cerrahi tedavisi ile başarılı sonuçlar elde edilmiştir. Bununla birlikte, humerus başının altında ortaya çıkan kavite, mekanik yetersizlik nedeniyle başarısızlığa yol açabilir. Yapısal allogreftler ile yapılan plak osteosentezi, başlangıç aşamasından kaynamaya dek yeterli mekanik desteği sağlayarak, baş çökmesi ile ilişkili komplikasyonlar oluşmasına engel olmaktadır.

Introduction The purpose of this study is to investigate the incidence of os acromiale in patients who had reverse shoulder arthroplasty (RSA) for rotator cuff tear arthropathy and the effect of presence of os acromiale on the functional results. Hypothesis We hypothesize than in the presence of os acromiale, the contraction strength of the deltoid would decrease due to the dynamic downward depression of the bony fragment leading to less favorable clinical results. Material and method Forty-six patients with a mean age of 70.8 who had RSA and a minimum follow-up of 24 months were included in this study. Preoperative radiographs, computerized tomography scans and magnetic resonance images were examined to determine the presence of os acromiale. Results Ten patients out of 46 (22 %) with os acromiale, all of which were of mesoacromion type, were followed up for 59.7 months. While both groups had significant improvements in Constant, Q-DASH and VAS scores compared to their preoperative status, a significant difference between the groups could not be found. The radiological evaluation showed that the average acromiohumeral distance significantly increased postoperatively in both groups. The acromiohumeral distance was significantly shorter in patients with os acromiale. Discussion While the presence of os acromiale does not have an adverse effect on the clinical results of the RSA, the loose fragment can migrate distally in the postoperative period due to the tension in the deltoid. Level of evidence III Case-control study.

Powerful contractions during epileptic seizures may cause shoulder dislocation and instability. The aim of the study is to evaluate the functional and radiographic results of the Latarjet procedure for anterior shoulder dislocation in patients with epilepsy and compare the functional results of these patients with the results of patients without epilepsy.Is latarjet procedure effective in epileptic patients as non-epileptic patients with anterior shoulder instability?Eleven shoulders of 9 patients with epileptic seizures causing anterior shoulder instability were evaluated retrospectively. All patients had a Latarjet procedure after neurologic evaluation and treatment arrangement. Epileptic seizures after the operation and shoulder dislocation after a seizure were investigated. For functional evaluation, ROWE, ASES and Constant scores were utilized whereas standard X-ray views were used for radiologic evaluation. The results of epileptic patients with Latarjet procedure were compared with non-epileptic patients (53 patients, 54 shoulders) for anterior shoulder instability.Three (33%) of the 9 epileptic patients had recurrent seizures after Latarjet procedure, whereas 1 of the 11 shoulders (9%) had dislocation after an epileptic seizure. Functional scores were found to be significantly improved in epileptic (P0.001) and non-epileptic patients (P0.001). No significant differences for functional results were found between epileptic and non-epileptic patients after Latarjet procedure for anterior instability (P0.05). One shoulder of 11 in the patients with epilepsy group (9%) and one shoulder of the 54 shoulders non-epileptic patients group (1.8%) had a redislocation. The rate of postoperative redislocation was significantly higher in patients with epilepsy (P=0.008).Epileptic patients have a high rate of recurrent seizures even with proper medical treatment. Significant functional improvements and shoulder stability may be achieved after Latarjet procedure in epileptic patients. These functional results were comparable with those of non-epileptic patients with Latarjet procedure for anterior shoulder instability.III (case-control study).

Von Willebrand disease (vWD) is the most common inherited bleeding disorder. The biggest challenge in the management of vWD is the difficulty in performing surgical procedures because of bleeding. Treatment guidelines recommend the use of pure von Willebrand factor or von Willebrand factor/factor VIII (vWF/FVIII) concentrate in patients with type 2 or type 3 vWD undergoing surgery, in patients with type 1 vWD undergoing surgery who are unresponsive, and in patients for whom desmopressin acetate is contraindicated. However, there is no consensus on the dosage and optimum levels of these factors to date. The aim of this study was to evaluate the perioperative management of patients with vWD during surgical procedures. Data pertaining to surgical procedures performed at our center from 2003 to 2014 were analyzed retrospectively. All operations, except one appendectomy, were elective, and a plan for the management of hemostasis was prepared for each patient. During this period, 37 surgical procedures (major, minor, and dental) were performed in 23 patients with vWD. Complications occurred in four out of 37 procedures (10.8%). No deaths or life-threatening bleeding occurred during any of the operations and no thromboembolic events were observed. The results from this retrospective study indicate that surgery can be safely performed by providing adequate and timely hemostasis during and after the procedure in patients with vWD. Perioperative and postoperative bleeding complications are rare when patients are closely and carefully monitored.

Latarjet, which is a coracoid bone block procedure, is an effective treatment for anterior shoulder instability with glenoid bone loss. During this reconstructive procedure the subscapularis may be tenotomized or be split to expose the glenoid neck. The aim of this study was to assess the effect of subscapularis management on functional outcomes and internal and external rotation durability and strength. Hypothesis is that the subscapularis split approach will result in better functional results and superior internal rotation strength and endurance. The study included 48 patients [median age 30 (range 16–69); 42 males, 6 females], who underwent a modified Latarjet procedure for anterior shoulder instability. There were 20 patients in the subscapularis tenotomy group and 28 patients in the subscapularis split group. The groups were compared isokinetically using a computerized dynamometer for internal and external rotation durability and strength. At the latest follow-up, the patients were evaluated with the American Shoulder and Elbow Surgeons (ASES) and ROWE scores for functional outcomes. At a median follow-up period of 25 (range 12–73) months after the Latarjet procedure, the internal rotation durability was significantly higher in the split group (p = 0.045). However, a statistically significant difference could not be found for internal and external rotational strengths (n.s.). There was also no significant difference between the final ASES and ROWE scores (n.s.). Although both approaches offer promising results, the subscapularis split approach appears to provide better internal rotation durability compared to subscapularis tenotomy. Therefore, the subscapularis split approach may be more preferable for the management of the subscapularis muscle during Latarjet procedure. Retrospective cohort study, Level III.

To investigate anatomic relation of standard and coaxial ankle arthroscopy portals with neurovascular structures during different degrees of ankle motion. Twenty posterior ankles of ten fresh cadavers were assessed. Posteromedial, posterolateral and coaxial (transmalleolar) portals were created using 4-mm Steinmann pins in accordance with the defined technique in neutral position. The ankles were then dissected, and the distance from the portals to the peroneal tendons, short saphenous vein and sural nerve was measured laterally and that from the tibial nerve, flexor hallucis longus tendon and posterior tibial artery was measured medially. Changes in the distance between these structures were noted in neutral positions, 15° of dorsiflexion and 30° plantar flexion. In the neutral position, the mean distance of the conventional posterolateral portal to the sural nerve was 6 mm (SD 2.9, range 2.7–14.5). The mean distance of the posterolateral coaxial portal to the peroneal tendon was 1.6 mm (SD 0.55, range 1.1–2.9). The mean distance of the posteromedial portal to the FHL was 2.11 mm (SD 1.1, range 0–4.7). The mean distance of the posteromedial coaxial portal to the posterior tibial artery was 6 mm (SD 1.4, range 3.9–9.5). Although not statistically significant, the distance between the portal and neurovascular structures increased in dorsiflexion for the portals placed posteriorly to the neurovascular structures and increased in plantar flexion for the portals placed anterior to the neurovascular structures. In comparison with the portals made in the neutral position, the distance between neurovascular structures and portals changes with portal placement in plantar flexion and dorsiflexion. In clinical practice, therefore, it might be safer to place the posteromedial–posterolateral portals in dorsiflexion and posterolateral–posteromedial coaxial portals in plantar flexion. The tibial nerve is closer to the posteromedial coaxial in dorsiflexion and could be in danger if making this portal with the foot in this position.

The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) is a standard shoulder assessment form, which is comprised of objective and subjective sections and prepared by shoulder and elbow surgeons. The purpose of this study was to translate the subjective part of the ASES into Turkish and establish its cultural adaptiveness and validity. The original version of the ASES was translated into Turkish in accordance with the stages recommended by Guillemin. Sixty-three patients (average age: 48.2 ± 13.4; range: 18–74 years) suffering from different shoulder complaints were included in the study. The ASES was completed twice at 3- to 7-day intervals for test–retest reliability. The intraclass correlation coefficient was used to calculate the test–retest reliability, and Cronbach’s alpha was used for internal consistency. Patients were asked to complete the short form 36 (SF-36) and the Shoulder Pain and Disability Index (SPADI) for correlation. Validity was evaluated by external correlation of the ASES with the SPADI and SF-S6 questionnaire, which may also be defined as ‘construct validity’. The results were analysed using Pearson’s correlation test. The test–retest reliability of the ASES pain and function subscales and total ASES score were 0.95, 0.86 and 0.94, respectively. Cronbach’s alpha coefficient for the total ASES was 0.88. The correlation between the total ASES and total SPADI score was −0.82; the correlation coefficient between the ASES pain subscale and SPADI pain subscale was −0.79 (p

Background Patients with obstetrical brachial plexus palsy (OBPP) sequela exhibit adduction and internal rotation contractures. The muscular imbalance may result in secondary bony changes. Tendon transfers and muscular releases may improve shoulder function in these patients. The aim of this study is to evaluate the functional and radiological results of pectoralis major tendon Z-plasty with transfer of latissimus dorsi and teres major tendons to rotator cuff tendons without release of subscapularis muscle in patients with mild sequela of OBPP. Materials and methods Twenty-six consecutive patients, who were treated with tendon transfer and met the eligibility criteria, were included in the study. No additional humeral osteotomy or subscapularis tenotomy was performed. Functional evaluation is made according to range of motion and Mallet scoring system. Preoperative radiologic evaluation was made according to the grading system of Waters. Results A significant increase in shoulder function was found in all patients. Postoperative radiographs revealed glenohumeral congruity was maintained in all patients. Improvement in shoulder abduction and external rotation was higher in patients who were operated before the age of 7. Discussion/conclusion Pectoralis major tendon lengthening with transfer of latissimus dorsi and teres major tendons to rotator cuff is an effective and reproducible technique and can improve shoulder functions in patients with OBPP. Subscapularis release is not always required to overcome internal rotation contracture. Secondary glenohumeral changes might also be prevented with this approach.

OBJECTIVES Arthroscopic rotator cuff surgery can result in severe postoperative pain. We compared a continuous subacromial infusion to a continuous interscalene block with levobupivacaine for patients undergoing arthroscopic rotator cuff surgery. METHODS Sixty patients were randomized to two groups: 1) interscalene block with 0.5% levobupivacaine (30 mL) followed by a postoperative subacromial infusion: 0.125% levobupivacaine 5 mL/h basal infusion, 5 mL bolus dose and a 20 min lockout time or; 2) interscalene block with 0.5% levobupivacaine (30 mL) followed by a postoperative interscalene infusion: 0.125% levobupivacaine 5 mL/h basal infusion, 5 mL bolus dose and a 20 min lockout time. Infusions were maintained for 48 hours. RESULTS The VAS scores in the postanesthesia care unit and at 4 h were not different. The VAS scores at 8, 12, 24, 36 and 48 h were lower than 4 in both groups; but they were significantly lower in the interscalene group. Additional analgesic requirements were lower in the interscalene group (16.6% vs 53.3%, p

Introduction: Hemophilia is a hereditary bleeding disorder that presents with primarily hemarthrosis and hematoma. The most common and frequent complication, especially in severe hemophilia, where factor VIII or IX is not administered prophylactically, is the hemophilic arthropathy that develops as a result of recurrent bleeding. In this study, the relationship between arthropathy development and timing of the prohylaxis and orthopedic interventions in hemophiliacs was presented. Materials and Methods: The data of 99 haemophilia (HA) and hemophilia B (HB) patients under the age of 25 years at our center were reviewed retrospectively. Age, type of disease, factor level, follow-up duration, prophylaxis dose and frequency, annual bleeding rate (ABR), target joints, arthropathic joints, applied radioactive synovectomy and orthopedic interventions were recorded. Results: Seventy-six HA and 23 HB were included. The median age was 14 (range 1-25) years old. Ten of them (10.1%) were mild, 15 (15.2%) were moderate and 74 (74.7%) were severe. Severe hemophiliacs were most of the patients in both types. Eighty-nine (89.9%) patients including 17 of mild-to-moderate type with target joint and / or surgical intervention were under prophylaxis and 10 (10.1%) were receiving on-demand therapy. The annual bleeding rate was 1.38. Twelve (12%) patients (8 HA, 4 HB) with degenerative hemophilic arthropathy had a mean age of 22 years old and a mean age of application was 12.3 years, a mean annual bleeding rate was 1.54 and a mean follow up and prophylaxis time was 9.5 years. Six patients (4 HA, 2 HB) with median age 21.8 years (range: 18-25) had 9 major orthopedic surgeries (arthrodesis (2), radial head resection (2), TEP, contracture releasing, acyloplasty, deformity correction, arthroscopic sinovectomy) and 22 patients with median age of 17.8 years had 29 minor orthopedic interventions (radiosynovectomy (28), closed reduction to femur fracture). Orthopedic interventions were performed at an advanced age, often who met with prophylaxis too late. Discussion: In our study, it has been shown that who had prophylaxis at an early age and prophylaxis for a longer period had less arthropathies which is the most important complication and additionally less arthroplasties. The fact that, the prevalence of permanent musclosceletal deformity was 59% before year 2000 (historical data) which reduced to 12% nowadays shows the sensitivity of hemophilia care in our center. Early and regular prophylaxis remains the most current treatment modality for the prevention of hemophilia complications. Disclosures No relevant conflicts of interest to declare.

Here, we report a series of 5 patients (6 shoulders) diagnosed with neuropathic arthropathy of the shoulder joint in our clinic between 2005 and 2008. Initial diagnosis, previous treatment, and radiological and clinical follow-up findings were reviewed. The mean age at diagnosis was 44.2 years. Four patients had unilateral and 1 patient had bilateral involvement. The presenting symptoms were pain, swelling, and loss in range of motion. Active forward flexion and abduction ranged from 0° to 90°. Hypoesthesia and loss of temperature sense was evident in 3 patients. Radiographs showed massive osteolysis of humeral head and glenoid process, and magnetic resonance imaging showed periarticular fluid collection, and degeneration at the rotator cuff and shoulder joint, resembling chronic septic arthritis or sarcoma. Biopsy was performed in 4 patients before definitive diagnosis, and synovial hypertrophy and necrotic bone was found. Two patients had a history of operated cervical syringomyelia, and the remaining 3 patients were later diagnosed to have syringomyelia and referred to neurosurgery clinic, where 2 of those were operated. Four patients were followed-up with symptomatic therapy, and 1 patient underwent an unsuccessful shoulder arthroplasty in another clinic. As a conclusion, neuropathic arthropathy of the shoulder is rare, and correct diagnosis is possible by careful physical and neurological examination and pathologic evaluation when needed.

Objectives: The role of intermittent ultrasound in the conservative treatment of subacromial impingement syndrome (SIS) has not been clarified. We aimed to evaluate the efficacy of ultrasound treatment in SIS.Methods: Thirty-six patients (29 females, 7 males; mean age 51 years; range 40 to 69 years) with type II SIS were randomized to two groups to receive intermittent ultrasound (group 1, n=20) and placebo ultrasound (group 2, n=16) for three weeks (15 sessions). All the patients received the same standard physical therapy and rehabilitation modalities besides ultrasound treatment. Evaluations were made before and three and six weeks after treatment. Functional results were assessed by the Constant score, pain was assessed by a visual analog scale, and range of motion was measured.Results: Within-group comparisons showed significant improvements in both groups three and six weeks after treatment (p0.05). The Constant score improved from 43.7±12.9 to 65.7±7.7 in group 1, and from 43.9±16.4 to 65.3±7.6 in group 2. Pain scores decreased from 5.5 to 2 and from 5 to 1 in group 1 and 2, respectively. Improvements in Constant scores and pain scores were similar in both groups (p>0.05).Conclusion: Our findings suggest that intermittent ultrasound added to conservative treatment of SIS do not provide an additional benefit to the patients., Amaç: Kesikli ultrasonun subakromiyal sıkışma sendromunun (SSS) tedavisindeki yeri şimdiye kadar yeterince incelenmemiştir. Bu çalışmada ultrasonun SSS’nin konservatif tedavisindeki etkisi araştırıldı.Çalışma planı: Tip II SSS tanısı konan 36 hasta (29 kadın, 7 erkek; ort. yaş 51, dağılım 40-69) randomize olarak iki gruba ayrıldı. Yirmi hastaya (grup 1) kesikli ultrason, 16 hastaya (grup 2) plasebo ultrason uygulandı. İki grupta da tedavi 15 seans (3 hafta) sürdürüldü. Tüm hastalara ultrason dışında aynı standart fizik tedavi ve rehabilitasyon programı uygulandı. Değerlendirmeler, tedaviden önce ve tedaviden üç ve altı hafta sonra yapıldı. Fonksiyonel sonuç Constant skoru, ağrı görsel analog skala ile değerlendirildi; hastaların hareket açıklıkları ölçüldü. Sonuçlar: İki grupta da tedavinin üçüncü ve altıncı haftalarındaki düzelmeler anlamlı bulundu (p0.05). Grup 1 ve 2’de tedavi öncesinde sırasıyla 43.7±12.9 ve 43.9±16.4 olan ortalama Constant skoru altıncı hafta sonunda 65.7±7.7 ve 65.3±7.6’ya yükseldi. Grup 1’de tedaviden önce 5.5 olan ağrı skoru son kontrolde 2’ye, grup 2’de ise 5’ten 1’e düştü. Constant skoru ve ağrı skorundaki düzelmeler iki grup arasında anlamlı farklılık göstermedi (p>0.05).Çıkarımlar: Bulgularımız, SSS tanısı konan hastaların konservatif tedavisinde kesikli ultrason uygulamasının ek yarar sağlamadığını göstermektedir.

Objectives: The purpose of this study was to determine the calcaneal angles on radiograms of individuals without a calcaneal fracture.Methods: We retrospectively analyzed a total of 308 digital records of lateral ankle or foot radiographs taken from 268 patients (106 males, 162 females; mean age 42 years; range 18-79 years) without a calcaneal fracture. On these radiographs, the reference lines were drawn with the use of an angle measurement software with a sensitivity of 1/100 mm and the Böhler (BA) and Gissane (GA) angles were measured. The distribution characteristics of the angles with respect to age, gender, and side of the body were analyzed and compared with those of previous studies.Results: The mean BA was 33.8±4.8° (range 20° to 46°) and the mean GA was 115.0±6.5° (range 100° to 133°). There were no significant differences for both angles with respect to measurements obtained from the right and left sides (for BA, p=0.198; for GA, p=0.601) and from both sexes (for BA, p=0.177; for GA, p=0.412). The highest (35.2°) and lowest (32.3°) means of BA were seen in the age brackets of 41-50 and 61-83 years, respectively. The corresponding age brackets for GA were 21-30 and 51-60 years with 115.7° and 114.4°, respectively. There were no significant differencesbetween the age groups for both angles (for BA, p=0.086; for GA, p=0.955). Of note, the mean BA was significantly higher than those reported in previous studies. There was no correlation between BA and GA (r=0.018; p=0.76), nor between the calcaneal angles and age (for BA, r=-0.092; p=0.11 and for GA, r=-0.070; p=0.22).Conclusion: The calcaneal angles show considerable variations in diverse ethnic groups and populations in terms of normal range, age, gender, and side. The ranges herein reported (20-46° for BA, 100-133° for GA) can be used as reference values for the Turkish population., Amaç: Kalkaneus kırığı bulunmayan kişilerin radyografilerinde ölçülen kalkaneus açılarının dağılımı ve normal sınırlarının belirlenmesi amaçlandı.Çalışma planı: Çalışmada, kalkaneus kırığı bulunmayan 268 hastaya ait (106 erkek, 162 kadın; ort. yaş 42; dağılım 18-79) 308 adet dijital yan ayak ve ayak bileği grafisi geriye dönük olarak incelendi. Bu grafiler üzerinde, 1/100 mm duyarlıkta açı ölçümü yapan bir yazılım yardımıyla referans çizgileri çizilerek, Böhler (BA) ve Gissane (GA) açıları ölçüldü. Açıların dağılım özellikleri, cinsiyet, yaş ve taraf ile olan ilişkileri incelendi. Saptanan dağılım özellikleri literatürdeki diğer çalışmaların sonuçlarıyla karşılaştırıldı. Sonuçlar: Böhler açısı ortalama 33.8±4.8° (dağılım 20°-46°), GA ise ortalama 115.0±6.5° (dağılım 100°-133°) bulundu. Her iki açı için sağ ve sol taraf ortalamaları arasında (BA için p=0.198; GA için p=0.601) ve cinsiyetler arasında (BA için p=0.177; GA için p=0.412) anlamlı fark bulunmadı. En yüksek (35.2°) ve en düşük (32.3°) ortalama BA değerleri sırasıyla 41-50 ve 61-83 yaş gruplarında görüldü. Gissane açısı için en yüksek (115.7°) ve en düşük (114.4°) ortalama değerler sırasıyla 21-30 ve 51-60 yaş grubunda idi. Yaş grupları arasında anlamlı farklılık saptanmadı (BA için p=0.086; GA için p=0.955). Ortalama BA değeri literatürdeki diğer sonuçlardan anlamlı derecede farklı bulundu. Korelasyon analizinde BA ve GA arasında anlamlı ilişki saptanmadı (r=0.018; p=0.76). Kalkaneus açılarıyla yaş arasında da anlamlı bir ilişki yoktu (BA için: r=-0.092; p=0.11 ve GA için: r=-0.070; p=0.22).Çıkarımlar: Kalkaneus açıları farklı ırk ve toplumlarda farklı normal sınırlar; yaş, cinsiyet ve tarafa göre farklı dağılım gösterebilir. Örnek grubumuzda saptanan BA için 20°-46°, GA için 100°-133° aralığı Türk toplumu için referans değerleri olarak kullanılabilir.

Objectives: We evaluated functional results of patients treated with open reduction and internal fixation with the parallel-plate technique for complex distal humerus fractures.Methods: Twenty-one patients (14 males, 7 females; mean age 47 years; range 16 to 85) underwent open reduction with olecranon osteotomy and internal fixation with the parallel-plate technique for distal humerus fractures accompanied by highly intra-articular or metaphyseal comminution (n=10), intra-articular comminution and osteoporosis (n=7), and intra-articular and metaphyseal comminution with bone loss (n=4). According to the AO classification, there were 12 C3, six C2, and three C1 type fractures. Eight patients had open fractures. The mean time to surgery was six days (range 1 to 17 days). Functional results were evaluated using the Mayo elbow performance score, Jupiter elbow score, and DASH (Disabilities of the Arm, Shoulder and Hand) score. The mean follow-up was 28 months (range 12 to 48 months).Results: The mean total range of motion was 90.2±31.1°, flexion was 118.1±17.4°, and extension was 27.8±17.4°. The mean Mayo elbow performance score and DASH score were 86.1±12.6 and 7.6±9.5, respectively. According to the Jupiter elbow scores, the results were excellent in seven patients, good in 11 patients, moderate in two patients, and poor in one patient. Radiographically, solid union was achieved in all the patients. Heterotopic ossification of varying degrees was seen in seven patients, two of whom underwent resection of heterotopic ossification due to severe limitation of movement. Debridement was performed in one patient due to the development of deep infection. Chondrolysis of the elbow occurred in one patient. Patients with open fractures had significantly lower range of motion than those with closed fractures (p0.05).Conclusion: Functional results are satisfactory in distal humerus fractures treated with stable osteosynthesis and parallel-plate technique that allow early active motion., Amaç: Kompleks humerus distal uç kırığı nedeniyle açık redüksiyon ve paralel plak tekniğiyle internal tespit uygulanan hastaların fonksiyonel sonuçları değerlendirildi.Çalışma planı: Kompleks distal uç humerus kırığı nedeniyle 21 hasta (14 erkek, 7 kadın; ort. yaş 47; dağılım 16-85) olekranon osteotomisi ile açık redüksiyon ve paralel plak tekniğiyle tedavi edildi. Kırıklara ileri derecede eklemiçi veya metafizer parçalanma (n=10), eklemiçi parçalanma ve osteoporotik özellikler (n=7), eklemiçi ve metafizer parçalanma ile birlikte kemik kaybı (n=4) eşlik etmekteydi. AO sınıflamasına göre, kırıkların 12’si C3, altısı C2, üçü C1 kırık idi. Sekiz hastada açık kırık vardı. Kırık ile ameliyat zamanı arasındaki süre ortalama altı gün (dağılım 1-17 gün) idi. Fonksiyonel sonuçlar Mayo dirsek performans skoru, Jupiter dirsek skoru ve Kol, Omuz ve El Engellilik (DASH) skoru ile değerlendirildi. Ortalama takip süresi 28 ay (dağılım 12-48 ay) idi.Sonuçlar: Toplam hareket açıklığı ortalama 90.2±31.1°, fleksiyon 118.1±17.4°, ekstansiyon 27.8±17.4° bulundu. Mayo dirsek performans skoru ortalama 86.1±12.6, DASH skoru 7.6±9.5 idi. Jupiter dirsek skoruna göre sonuçlar yedi hastada mükemmel, 11 hastada iyi, iki hastada orta, bir hastada kötü olarak değerlendirildi. Radyografik olarak, hiçbir hastada kaynama sorunuyla karşılaşılmadı. Yedi hastada (%33.3) değişik derecelerde heterotopik ossifikasyon görüldü; iki hastaya ciddi hareket kısıtlılığı nedeniyle heterotopik ossifikasyon rezeksiyonu yapıldı. Bir hastada derin enfeksiyon nedeniyle debridman yapıldı. Bir hastada ise dirsek ekleminde kondroliz gelişti. Açık kırıklı hastaların hareket açıklığı anlamlı derecede daha düşük bulunurken (p0.05). Çıkarımlar: Erken harekete izin verecek stabilitede osteosentez tekniği ve paralel plaklama tekniği ile tedavi edilen distal humerus kırıklarında fonksiyonel sonuçlar tatmin edicidir.

Objectives: Despite the developments in chemotherapy protocols, improvement in the survival rates of osteosarcoma has been limited. We evaluated the effect of certain prognosis-related proteins on survival of patients with osteosarcoma.Methods: Data from 45 patients (24 males, 21 females) who were treated and followed-up for osteosarcoma were reviewed. Following neoadjuvant chemotherapy, 41 patients underwent extremity saving surgery, and four patients underwent amputation. The most frequent localization was the lower end of the femur (n=23, 51.1%), followed by the upper end of the tibia (n=10, 22.2%). Three patients had metastasis on admission. Surgical resection samples were retrieved from the pathology archive and analyzed immunohistochemically for the expression of p-glycoprotein p170, p53, heat-shock protein 27 (HSP27), HSP90, and nm23. The effect of these proteins on prognosis and survival was assessed with survival analysis using the Kaplan-Meier method. The mean follow-up was 49.7 months (range 6 to 185 months).Results: Three patients with metastasis on admission died within five years due to pulmonary metastasis. New metastases developed in 29 patients. Total 5-year and 10-year survival rates were 60% and 43%, respectively. The corresponding diseasefree survival rates were 41% and 24%. Five-year survival was 29% in patients who developed metastasis. Among clinical factors, survival was influenced only by the presence of metastasis on admission (p=0.044). Five-year and 10-year survival rates were significantly different between patients with and without p53 positivity (p=0.04), while the other proteins were not significantly associated with survival.Conclusion: Our data suggest that p53 may be used as a prognostic marker in osteosarcoma due to its significant association with survival., Amaç: Kemoterapi rejimlerindeki gelişmelere rağmen osteosarkom sağkalımında çok az ilerleme olmuştur. Bu çalışmada, osteosarkomlu hastalarda prognoz ile ilişkili bazı proteinlerin sağkalım ile ilişkisi değerlendirildi.Çalışma planı: Tedavisi ve izlemi hastanemizde yapılan 45 hastanın (24 erkek, 21 kadın) verileri geriye dönük olarak incelendi. Osteosarkom nedeniyle, neoadjuvan kemoterapi sonrasında, 41 hastaya ekstremite koruyucu cerrahi, dört hastaya amputasyon yapılmıştı. En sık tutulum 23 hasta (%51.1) ile femur alt uç, 10 hasta (%22.2) ile tibia üst uçta görüldü. Üç hastada başvuru anında metastaz vardı. Cerrahi rezeksiyon örnekleri patoloji arşivinden çıkartılarak, p-glikoprotein p170, p53, ısı şok proteini 27 (HSP27), HSP90 ve nm23 proteinlerinin ekspresyonu immünohistokimyasal yöntemlerle incelendi. Bu proteinlerin prognoz ve sağkalım üzerindeki etkileri Kaplan-Meier yöntemi ile değerlendirildi. Hastaların ortalama takip süresi 49.7 ay (dağılım 6-185 ay) idi.Sonuçlar: Başvuru anında metastaz saptanan üç hasta beş yıl içinde akciğer metastazından yaşamını yitirdi. Yirmi dokuz hastada metastaz gelişti. Beş ve 10 yıllık genel sağkalım oranları sırasıyla %60 ve %43 bulundu. Hastalıksız sağkalım oranı ise beş yıl için %41, 10 yıl için %24 idi. Metastaz gelişen hastalarda beş yıllık sağkalım oranı %29 idi. Klinik faktörler içinde, sağkalımı anlamlı etkileyen sadece başvuru anında metastaz varlığı idi (p=0.044). p53 proteininin pozitif ve negatif ekspresyonları arasında beş yıl ve on yıllık sağkalım oranları açısından anlamlı fark görülürken (p=0.04), incelenen diğer proteinler sağkalımla ilişkili bulunmadı.Çıkarımlar: p53 ekspresyonu ile sağkalım arasındaki ilişki, p53’ün osteosarkomda prognostik gösterge olarak kullanılabileceğini düşündürmektedir.

The purpose of this study was to determine the effectiveness of the microfracture technique in the treatment of full-thickness articular cartilage lesions of the knee.In this study the midterm results of 90 patients (47 women and 43 men) with focal full-thickness articular cartilage lesions who had been managed with the microfracture technique are presented. The mean age of our patients was 34.5 years (range, 20 to 58), and 51 right and 39 left knees were treated. All of the articular lesions involved medial femoral condyles.On the basis of follow-up at a mean of 68 months (range, 24 to 108 months), mean improvements in Lysholm knee scores (from 54.2 to 84.6 points), Tegner activity scale scores (from 2.6 to 5.2 points), and Oxford knee interrogation scores (from 23.1 to 44.8 points) were observed (P.0001). Moreover, there was a strong and significant correlation between functional results and age younger than 35 years, size of defect less than 2 cm(2), non-weight-bearing surface, and body mass index lower than 25 kg/m(2), respectively (P.001).According to our midterm results, the microfracture technique is quite effective with regard to the improvement of daily activities with a favorable impact on pain relief and better functional results. Furthermore, we found that there was a correlation between functional results and age, size of defect, location of defect, and body mass index as prognostic parameters.Level IV, therapeutic case series.

We compared time-dependent changes in the biomechanical properties of single-and double-row repair of a simulated acute tear of the rotator cuff in rabbits to determine the effect of the fixation techniques on the healing process. A tear of the supraspinatus tendon was created in 80 rabbits which were separated into two equal groups. A single-row repair with two suture anchors was conducted in group 1 and a double-row repair with four suture anchors in group 2. A total of ten intact contralateral shoulder joints was used as a control group. Biomechanical testing was performed immediately post-operatively and at four and eight weeks, and histological analysis at four and eight weeks. The mean load to failure in group 2 animals was greater than in group 1, but both groups remained lower than the control group at all intervals. Histological analysis showed similar healing properties at four and eight weeks in both groups, but a significantly larger number of healed tendon-bone interfaces were identified in group 2 than in group 1 at eight weeks (p < 0.012). The ultimate load to failure increased with the number of suture anchors used immediately post-operatively, and at four and eight weeks. The increased load to failure at eight weeks seemed to be related to the increase in the surface area of healed tendon-to-bone in the double-row repair group.

Objectives: To compare 3 different fixation methods for the treatment of humeral shaft nonunions in terms of union time, functional outcome, and complications. Design: Retrospective case series. Setting: University hospital. Patients: Between 1996 and 2004, 80 patients (mean age, 49; range, 15 to 86; 30 women and 50 men) with nonunions of the humeral shaft were treated surgically in our institution. Circular external fixators (CEF) were used in 35 patients, unilateral limb reconstruction system (LRS) fixators in 24 patients and fixation with plates in 21 patients. Intervention: Surgical procedure included hardware removal in previously operated patients, autogenous grafting in all patients in the plate group and in those patients with atrophic nonunions in the external fixator groups, compression of the nonunion site in all patients. Main Outcome Measurements: Radiological union time, complications, shortening, and disabilities of the arm, shoulder, and hand (DASH) score. Results: Mean follow-up period was 48.1 months (range, 12 to 121). Mean radiological union time was 5.5 months (range, 1.5 to 12) in the CEF group, 5.2 months (range, 3 to 10) in the LRS group, and 5.7 months (range, 3 to 12) in the plate group. Mean DASH score was 23.7 in the CEF group, 18.6 in the LRS group, and 26 in the plate group. There were no statistical differences in terms of union time and the DASH score among the 3 groups. Successful union was achieved in 77 (96.3%) patients. Conclusion: Both external fixation and plate fixation produce excellent results in humeral shaft nonunions if applied properly. The procedure can be tailored to the surgeon's experience, keeping in mind that plate fixation demonstrates a longer healing time in those cases that had previous surgeries.

Objectives: The purpose of this study was to evaluate early postoperative biomechanical changes in plicated joint capsules and to determine the effect of debridement to create a bleeding inner capsular surface on the healing process.Methods: Fifty-four mature New Zealand white rabbits were used. Plication was performed in unilateral medial knee joint capsules of 48 rabbits either alone (n=24) or following debridement (n=24) to create a bleeding inner capsular surface. Six rabbits remained untreated for the control group. The operated knee joints were immobilized in flexion postoperatively. The rabbits from the two study groups were sacrificed in groups of six immediately after operation, in the first, second, and third weeks, of which five were evaluated in tensile tests and one was evaluated histologically.Results: Compared to the controls, tensile strengths were significantly higher in both study groups until the third week (p0.05). The strength of the plicated capsules was significantly higher in the first week in both study groups than those measured in subsequent weeks (p0.05). Compared to its absence, the use of debridement was associated with a significantly lower strength in the first week (p0.05). Histological findings were similar in the two study groups and were characterized by healing with increased fibrosis starting from the first week.Conclusion: A plicated capsule would not be weaker than an intact one. Our findings do not favor debridement for a more rapid and better healing process. Rather, it might have adverse effects on the biomechanical properties of the capsule., Amaç: Plikasyon uygulanan eklem kapsülünde ameliyat sonrası erken dönemde meydana gelen biyomekanik değişimler araştırıldı ve debridman ile kapsül iç yüzünde kanamalı bir yüzey oluşturulmasının iyileşme üzerine etkisi değerlendirildi.Çalışma planı: Elli dört yetişkin Yeni Zelanda beyaz tavşanının 48'inin tek taraf diz medial eklem kapsülüne tek başına (n=24) ya da debridmanla kapsül iç yüzünde kanamalı bir yüzey oluşturulduktan sonra (n=24) plikasyon yapıldı. Altı tavşanın sağlam dizi kontrol grubunu oluşturdu. Ameliyat sonrasında tavşanların dizleri tespit edildi. Debridman uygulanan ve uygulanmayan gruplarda altışar tavşanın yaşamı sırasıyla ameliyattan hemen sonra, birinci ikinci ve üçüncü haftalarda sonlandırıldı. Her altgrupta beş tavşan mekanik testler için, bir tavşan ise histolojik değerlendirme için kullanıldı.Sonuçlar: Deney gruplarında kopma kuvveti üçüncü haftaya kadar kontrol grubundan yüksek bulundu (p0.05). Ayrıca, birinci haftadaki kopma kuvveti, ikinci ve üçüncü hafta sonuçlarından anlamlı derecede yüksekti (p0.05). Debridman uygulanmayan gruba göre, debridman uygulanan grubun birinci haftadaki kopma kuvveti belirgin olarak daha azdı (p0.05). Histolojik örneklerde deney gruplarında tüm haftalarda benzer bulgular elde edildi; birinci haftadan itibaren her iki grupta da artan fibrozisle birlikte iyileşme gözlendi.Çıkarımlar: Plikasyondan sonra kapsül, sağlam kapsülden daha zayıf değildir. Debridmanla daha hızlı veya daha iyi iyileşme olduğu gösterilememiştir. Debridman kapsülün biyomekanik özelliklerini olumsuz etkileyebilir.

Objective: The purpose of this study was to evaluate the functional and radiological results of semiconstrained Coonrad-Morrey total elbow arthroplasty for distal humeral nonunions in the mid-term period.Methods: Seven patients were treated with Coonrad-Morrey total elbow arthroplasty for distal humeral nonunion. All patients were female, and the mean age was 65.6 years (range: 64–68 years). Patients were followed for at least 5 years, and the mean follow-up time was 73 months (range: 63–84 months). Anteroposterior and lateral radiographs at preoperative and early postoperative period of the joint replacement and latest follow-up were used to detect postoperative radiological changes in terms of loosening. The Mayo Elbow Performance Index (MEPI) and Q-DASH Score were used for functional evaluation.Results: At the latest follow-up, joint stability had been achieved in all 7 patients. Six patients (85.7%) were pain free. The mean range of motion was 30° (range: 0–60°) preoperatively, and this improved to 90.7° (range: 60–110°) at the latest follow-up (p, Amaç: Bu çalışmada, distal humerus kaynamamalarının tedavisinde Coonrad-Morrey total dirsek protezinin orta dönem fonksiyonel ve radyolojik sonuçlarının değerlendirilmesi amaçlandı.Çalışma planı: Distal humerus kaynamama nedeniyle 7 hastaya Coonrad-Morrey total dirsek artroplastisi uygulanmıştır. Tamamı kadın olan n hastaların ortalama yaşı 65.6 idi. Ortalama takip süresi 73 ay iken minimum takip süresi 5 yıl olarak tespit edilmiştir. Ameliyat öncesi, hemen sonrası ve son kontrolde elde edilen dirsek anteriorposterior ve lateral grafileri ile radyolojik değişiklikler ve gevşeme değerlendirilirken, Mayo Elbow Performance Index (MEPI) ve Q-Dash skorları fonksiyonel değerlendirmede kullanılmıştır.Bulgular: Son kontrolde, 7 hastada da dirsek stabilitesinin sağlandığı görüldü. 6 hastanın(%87.5) ağrısı yoktu. Ameliyat öncesi 30° olan ortalama hareket açıklığının , son kontrolde ortalama 90.7° ye arttığı tespit edildi (p

BackgroundFailure load of the tendon–fixation material–bone unit has a crucial importance for the rehabilitation protocol after tenodesis procedures.PurposeTo investigate and compare the time-dependent changes in fixation strengths of 3 proximal biceps tenodesis techniques.Study DesignControlled laboratory study.MethodsTwo intraosseous techniques (suture sling and tenodesis screw) and 1 extraosseous technique (2 suture anchors) were investigated. Biceps tenodesis was performed on 45 shoulders of 26 sheep, 15 shoulders for each technique. Twelve similar cadaveric sheep shoulders (4 for each technique) provided the day 0 results. Sheep were sacrificed at 3, 6, and 9 weeks, and specimens were tested for the failure load of the tenodeses.ResultsAll 3 tenodesis techniques were found to have similar failure loads at all time intervals tested. All 3 curves remained below the failure load of the intact tendon (862 ± 96 N) and above their day 0 results for the study period; similarly, at each time interval, results tended to be better compared to the previous test. The tenodesis screw group exhibited significantly higher failure loads at week 3 (419 ± 53 N) compared to day 0 values (164 ± 45 N) (P=. 009). The same level of significance was observed at week 6 in the remaining 2 groups.ConclusionTenodesis of the biceps tendon on the proximal humerus at an extra-articular site does not weaken after surgery. The tenodesis screw group had a significantly higher increase in the fixation strength within the first 3 weeks.Clinical RelevanceNo significant differences could be found between the failure loads of all 3 investigated tenodeses for the first 9 weeks.

Introduction Powerful contractions during epileptic seizures may cause shoulder dislocation and instability. The aim of the study is to evaluate the functional and radiographic results of the Latarjet procedure for anterior shoulder dislocation in patients with epilepsy and compare the functional results of these patients with the results of patients without epilepsy. Hypothesis Is Latarjet procedure effective in epileptic patients as non-epileptic patients with anterior shoulder instability? Material and method Eleven shoulders of 9 patients with epileptic seizures causing anterior shoulder instability were evaluated retrospectively. All patients had a Latarjet procedure after neurologic evaluation and treatment arrangement. Epileptic seizures after the operation and shoulder dislocation after a seizure were investigated. For functional evaluation, ROWE, ASES and constant scores were utilized, whereas standard X-Ray views were used for radiologic evaluation. The results of epileptic patients with Latarjet procedure were compared with non-epileptic patients (53 patients, 54 shoulders) for anterior shoulder instability. Results Three (33 %) of the 9 epileptic patients had recurrent seizures after Latarjet procedure, whereas 1 of the 11 shoulders (9 %) had dislocation after an epileptic seizure. Functional scores were found to be significantly improved in epileptic (P 0.05). One shoulder of 11 in the patients with epilepsy group (9 %) and one shoulder of the 54 shoulders non-epileptic patients group (1.8 %) had a redislocation. The rate of postoperative redislocation was significantly higher in patients with epilepsy (P: 0.008). Discussion Epileptic patients have a high rate of recurrent seizures even with proper medical treatment. Significant functional improvements and shoulder stability may be achieved after Latarjet procedure in epileptic patients. These functional results were comparable with those of non-epileptic patients with Latarjet procedure for anterior shoulder instability. Level of evidence III (case-control study).

Background and objectives: The aim of the study were to demonstrate the possible hemodynamic changes and cerebral blood flow alterations in patients who were positioned from supine to beach chair position; and to detect if the position change causes any cortical activity alteration as measured by the 4-channeled electroencephalography monitor. Methods: 35 patients were included. Before the induction, mean arterial pressure and patient state index values were recorded (T0). After the intubation, doppler-ultrasonography of the patients’ internal carotid and vertebral arteries were evaluated to acquire cerebral blood flow values from the formula. In supine position, mean arterial pressure, patient state index and cerebral blood flow values were recorded (T1) and the patient was positioned to beach chair position. After 5 min all measurements were repeated (T2). Measurements of patient state index and mean arterial pressure were repeated after 20 (T3), and 40 (T4) min. Results: There was a significant decrease between T0 and T1 in heart rate (80.5 ± 11.6 vs. 75.9 ± 14.4 beats/min), MAP (105.8 ± 21.9 vs. 78.9 ± 18.4 mmHg) and PSI (88.5 ± 8.3 vs. 30.3 ± 9.7) (all p