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Soft tissue injuries associated with malleolar fracture−dislocations may increase postoperative rates of wound complication. Ankle-spanning frame plays a fundamental role in the local damage control orthopedics while gaining time for definitive surgery. The objective of this study was to evaluate the effect of a 2-stage surgery for the unstable malleolar fracture−dislocations with severe soft tissue injuries compared to a 1-stage surgery in terms of the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot−ankle and Olerud-Molander ankle scores (OMAS). We analyzed 45 patients who met our study criteria. The patients were divided into 2 groups according to staged surgeries. Demographic data of patients, comorbidities, alcohol and tobacco use, Tscherne soft tissue injury scores, the AOFAS hindfoot−ankle and OMAS, postoperative complications, total hospitalization times, waiting time between stages, and waiting time from admission to surgery times were investigated. There was a statistically significant difference between the groups in terms of the mean total hospitalization times (p =.007), waiting time from admission to surgery (p <.001), gender (p =.005), and Tscherne soft tissue injury scores (p <.001). The mean AOFAS hindfoot−ankle and OMAS of the groups did not differ statistically at a minimum of 12 months of the follow-up period (p =.094 and p =.126, respectively). A 2-stage surgery can be performed safely in the carefully selected patients with the unstable malleolar fracture−dislocations with Tscherne grades 2 and 3 soft tissue injuries, and this surgery does not affect the postoperative AOFAS hindfoot−ankle and OMAS statistically compared to a 1-stage surgery at a minimum of 12 months of the follow-up period. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to biomechanically compare three different fixation methods for the fixation of anterior column posterior hemitransverse type acetabular fracture (ACPHT).Methods: ACPHT fracture models were created on twenty-four foam cortical shell artificial hemipelvis models. Three fixation methods were assessed - Group 1: posterior column lag screws over a suprapectineal plate; Group 2: Posterior column lag screws over a suprapectineal plate and an infrapectineal plate; Group 3: A suprapectineal plate and a vertical infrapectineal plate. Stiffness and displacement amounts of fixation methods under dynamic and static axial loading conditions were measured.Results: In the dynamic and static tests, Group 3 showed the less stable fixation compared to Group 2. There was no statistically significant difference between the stiffness values of the fixation groups. In the static tests, there was no statistically significant difference between Group 1 and 2, although less displacements were obtained in Group 2.Conclusions: A combination of posterior lag screws over a suprapectineal plate and an infrapectineal plate supporting the pelvic brim along both sides of the linea terminalis resulted in a better fixation construct than a suprapectineal plate accompanying with a vertical infrapectineal plate provide better stability with less fracture displacement. [ABSTRACT FROM AUTHOR]

Pauwels Type III fractures are unstable and frequently treated with cannulated screws (CS) or dynamic hip screws (DHS). The newly developed talon-cannulated compression devices (TCCD) have the potential to provide rotational stability, mainly through their talon. The study investigates whether TCCD has mechanical advantages over conventional screws or can be as stable as DHS in a reverse triangle configuration for an unstable femoral neck fracture. After creating a standard Pauwels Type III unstable femoral neck fracture in 36 synthetic femur bones in cortical/hard cancellous bone density, 18 were reserved for dynamic-static tests, and 18 were used for torsional tests. Each group containing 18 synthetic bones was divided into three groups to apply three different fixation materials (CS, DHS, and TCCD), with six models in each group. The displacement amounts after dynamic-static tests were measured using the AutoCAD program according to the reference measurement criteria. During the dynamic tests, a series of photographs were taken. During the static tests, the beginning and post-test photographs were taken. Finally, torsional tests were performed until implant failure occurred in the synthetic femur. In static axial loading tests, TCDD was found to be statistically superior to conventional CS in AL-BL distance (p = 0,014) and CL distance (p = 0,013) measurements, and there was no significant difference between the other groups. There was no significant difference between all groups in dynamic axial compression tests in any points of interest. In torsional tests, TCCD outperformed cannulated screws in stiffness (p = 0,001) and maximum torque (p = 0,001) categories, and they provided statistically significant superiority to DHS in yield torque (p <0,001) category. Biomechanically, TCCD predominates conventional cannulated screws in femoral neck fractures. TCCD also has superior torsional properties than DHS in the yield torque category. Therefore, TCCD could be the implant of choice for unstable femoral neck fractures. [ABSTRACT FROM AUTHOR]

To compare the amount of displacement and rigidity at the fracture line under static & dynamic axial loading and torsional stress of conventional cannulated screw (CS), plate screw fixation including inter-fragmentary screw (PL), and talon cannulated compression device or talon screw in other words (TS) in posterior column fracture models. Synthetic hemipelvis bone models presenting a posterior column fracture were used in this study. Group PL, CS, and TS were created with ten bone models prepared for each group for dynamic and static loading tests and another ten for torsional tests. Rigidity and displacement amounts before and after loading were measured at the reference points AL, BL, and CL, located at the acetabulum's top, middle, and bottom, respectively. Torsional tests for each group were used to calculate torsional rigidity and maximum torque values. In dynamic axial loading tests, Group CS showed more displacement than PL at the BL point (p = 0,032) and Group TS at AL (p = 0,032) and CL (p = 0,004) points. In static axial loading tests, Group CS significantly displaced more than TS at AL and CL points (p = 0,05 and p = 0,014, respectively). Group PL and Group TS exhibited similar behavior in dynamic, static axial loading tests and torsional rigidity. The maximum torque that Group PL could withstand was statistically significantly higher than the other two groups (p <0,001). Talon cannulated screws had promising results in posterior column fractures of the acetabulum, which may decline the need for open surgery for stable fixation. [ABSTRACT FROM AUTHOR]

Alkaptonuria is a hereditary disorder of phenylalanine and tyrosine, with an incidence of approximately 1/200,000 to 1/1,000,000. Ochronosis is the accumulation of homogentisic acid and its metabolites in connective tissues such as the tendons, cartilage, and skin. In the present case study, a 50-year-old male presented with a nontraumatic calcaneal avulsion without a previous diagnosis of ochronosis. To the best of our knowledge, little information has been reported of this pathology in the Achilles tendon and the surgical management. [ABSTRACT FROM AUTHOR]

Background Percutaneous iliosacral screw fixation of the posterior pelvic ring is a demanding procedure with high exposure to radiation. The conventional technique includes the use of three classical projections with the C-arm: inlet, outlet, and true lateral views. A projection in the axis of the upper sacral alar pedicles with a 30° cephalad and 30° ventral oblique view would help in obtaining a more accurate visualization of the safe corridor. Two subcutaneously placed K-wires, one placed horizontally and one vertically, may facilitate the starting point and aim changes by offering the surgeon an option for exactly matching the position of the sacrum with the image. The purpose of this study was to detect if the radiation application could be decreased by our new methodology. Methods Seventeen patients with pelvic posterior ring disruptions, in which percutaneous iliosacral screw placement was indicated, were included in the study. Group 1 comprised 7 patients in whom conventional projections and technique were used. Group 2 comprised 10 patients in whom 30°–30° projection and sacral mapping technique via two subcutaneous K-wires were applied. Radiation exposure time, total fluoroscopic shot count, fluoroscopic shot count needed for only guide wire and screw placement, radiation dose, and complications were compared between the two groups. Results The median number of fluoroscopic images for guide and screw placement was 132 (56–220) and 29.5 (19–83) in Groups 1 and 2, respectively, and the difference was statistically significant ( p < 0.001). The median total fluoroscopic radiation time was 138 (68–234) and 52 (28–77) s in Groups 1 and 2, respectively, and the difference was significant ( p < 0.001). Group 1 had a significantly higher median radiation dose than Group 2 [3020 (1502–6032) vs. 1192 (426–2359); ( p = 0.001)]. Conclusions Iliosacral screw placement with the help of sacral mapping and a fourth view, “30°–30°”, helps the surgeon to markedly reduce the fluoroscopic shots, radiation time and dose during guide wire and screw placement. Level of evidence Therapeutic, Level II. [ABSTRACT FROM AUTHOR]

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 (≤ 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 ≥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 ≥8 cm in length. [Copyright &y& Elsevier]

Abstract: 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. [Copyright &y& Elsevier]

Abstract: 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. [Copyright &y& Elsevier]

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, Brown''s 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 [Copyright &y& Elsevier]

• Micro-CT results revealed a significant increase in bone/tissue volume in cubic boron nitride coating compared to control. • Cubic and hexagonal types of boron nitride coating had superior fracture healing features compared to control group. • Cubic boron nitride coating can accelerate the fracture healing and could lead to shorten of union time. Boron nitride is a biocompatible and an osteo-inductive material for orthopedic applications. The aim of this study was to evaluate the effects of two different allotrope boron nitride coated implants, cubic boron nitride and hexagonal boron nitride, on fracture healing. In this experimental study, a total of 24 rats were divided into three groups. Group A was the control group with Kirschner wire without coating, while the wires were coated dominantly by cubic boron nitride in Group B and hexagonal boron nitride in Group C. Then a mid-third femoral fracture was created. The fracture healing was examined in terms of new bone formation with micro-CT analysis and histopathological examination, quantitative measurement of bone turnover metabolites and scintigraphic examination of osteoblastic activity on 28th day post fracture. Micro-CT measurement results revealed a statistically significant increase in bone volume/tissue volume ratio and bone surface values in group B compared to group A. Cortex diameter and osteoblast counts were statistically higher in group B compared to group A. Inflammatory response was increased in group C compared to groups A and B. Biochemical test results showed significantly increased alkaline phosphatase levels and decreased osteocalcin levels in group B compared to group A. The increase in serum phosphorus and decrease in serum calcium levels was statistically significant in group C compared to Group A. Both types of boron nitride coating had superior fracture healing features compared to control group. Therefore, c-BN coating can accelerate the fracture healing and could lead to shorten of union time. [ABSTRACT FROM AUTHOR]

Aims: The aim of the study was to test if the addition of CGF to the Masquelet technique contributes to the quality of the membrane formed surrounding the polymethylmethacrylate (PMMA), in terms of inflammation, proliferation and vasculazition in the Masquelet technique in the early and late phases in a rabbit model.Materials and Methods: A critical bone defect of 15 mm was created in radius diaphysis, leaving 3 cm of intact bone to the joint. To mimic the Masquelet technique and to increase stability, a 6-hole 1.5 mm plate with two screws was applied, although it was initialy stable because of the inherently fixed ulna and radius both proximally and distally in the rabbits. Group 1 and Group 3, were soleley treated with the Masquelet technique as control groups, and were sacrificed at 3 and 6 weeks, respectively. Group 2 and Group 4, were treated with the Masquelet technique + CGF prepared from the rabbit blood groups, and were sacrificed at 3 and 6 weeks, respectively. The groups were compared histopathologically and immunohistochemically, in respect of the means of thickness of the membrane and ratio of elastic fibers, membrane vascularization (CD31), inflammation (MAC387), proliferation (Ki67), and presence of stem cells (STRO-1).Results: Thickness of the membrane and CD31 values were significantly higher in Group 4 than Group 3 (p = 0.004 for both). MAC387 was statistically significantly higher in Group 2 compared to Group 1 and Group 4 compared to Group 3 (p = 0.04 for both). Ki67 was significantly higher in Group 2 compared to Group 1 and Group 4 compared to Group 3 (p = 0.05 and p = 0.006, respectively). Proliferation in the membrane was statistically significantly higher in Group 2 compared to Group 1 (p = 0.05). Likewise, the proliferation index of Group 4 was statistically significantly higher than Group 3 (p = 0.06). STRO-1 was significantly higher in Group 2 compared to Group 1 (p = 0036).Conclusion: The addition of CGF to the Masquelet technique contributes to the quality of the membrane formed, in respect of inducing inflammation and proliferation, maintaining vascularization on large diaphyseal bone defects, and increasing the number of stem cells. [ABSTRACT FROM AUTHOR]

Abstract: 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. [Copyright &y& Elsevier]

Abstract: Introduction: Thromboembolic complications are the most common preventable cause of mortality and morbidity in trauma and arthroplasty patients. Therefore, this group of patients receive a prophylaxis for thromboemboli by mechanical or pharmacological methods. This study was designed to evaluate the effect of enoxaparin, nadroparin, dalteparin and fondaparinux on fracture healing in an experimental rat femur fracture model. Materials and Methods: Thirty male, Wistar-Albino rats were divided randomly into five groups. A retrograde intramedullary kirschner wire was inserted under general anesthesia and then standard closed femoral shaft fractures were produced. After the production of fractures, treatment groups received enoxaparin, nadroparin, dalteparin and fondaparinux via subcutaneous injections and the control group received placebo injections for four weeks. The formation and healing of the bones were determined by clinical manual evaluation, radiographic and histopathological analyses. Results: Histological callus formation scores were found to be significantly increased in the fondaparinux group when compared to the control group at the end of the fourth week. Other treatment groups’ histological scores did not show any significant difference with the control group. The histological scores of all groups were compared and the fondaparinux group histological score was found to be significantly increased. The clinical and radiological scores between the groups did not show any significant difference. Conclusions: A positive histological effect of fondaparinux on fracture healing was observed in this study. This enhancing effect of fondaparinux may be related to its synthetic and selective composition and non-inhibitory effects on osteoblasts and growth factors. [Copyright &y& Elsevier]