Augmentation with a non-vascularized autologous fibular graft for the management of Cierny-Mader type IV chronic femoral osteomyelitis: a salvage procedure

PURPOSE

The study aimed to evaluate preliminary clinical and radiographic results of patients with Cierny-Mader type IV chronic femoral osteomyelitis and augmented with a non-vascularized fibular autograft as a salvage procedure because of the poorly regenerated new bone after bone transport over an intramedullary nail (BTON).

METHODS

Patients diagnosed with CM type IV chronic femoral bone infection and treated with BTON procedure between 2003 and 2020 were retrospectively reviewed. Seven patients were included in the study whose distraction gap was poorly regenerated and then augmented with a non-vascularized fibular autograft. A three-stage treatment was administered. First, the infection was eradicated. Second, BTON was performed. Third, the poorly regenerated distraction gap was augmented with a fibular autograft before removing the external fixator (EF). Clinical and radiological results were evaluated based on the criteria described by Paley-Maar and Li classification.

RESULTS

The mean patient age was 52 years. The mean treatment time was 24.8 months, with a mean femoral lengthening of 12.6 cm. The mean EF and bone healing indexes were 0.57 months/cm and 0.8 months/cm, respectively. The mean length of the fibular graft was 13 cm. The bone healing of new bones was achieved in all patients with good quality after grafting. Functional scores were excellent in four patients. No patients experienced any sequelae.

CONCLUSIONS

Non-vascularized fibular autograft augmentation may be an effective salvage procedure for poorly regenerated new bone after BTON to manage chronic femoral bone infection.

Spinal Melorheostosis: A Rare Presentation

CASE

A 22-year-old female patient was referred to the orthopaedic department for further examination after a radiopaque area was observed in the T6 vertebra in her chest radiograph. Computed Tomography (CT) showed a sclerotic mass with smooth borders, involving the entire body of the T6 vertebra, left posterior elements, posterior of the rib past the left zygapophyseal joint, and a "flowing candle wax" image toward the T7 vertebra. Spinal melorheostosis was considered radiologically in the patient, but malignancy could not be completely excluded. Thereupon, open biopsy was performed under general anesthesia.

CONCLUSION

Spinal melorheostosis is a rare condition. Histological examination should be considered in cases where the diagnosis remains suspicious after clinical and radiological evaluations.

The effect of pharmacological treatment in combination with vitamin K on healing in an experimental rat model of osteoporosis

OBJECTIVES

This study aims to compare the effects of teriparatide, zoledronic acid, and their combination therapy with vitamin K on osteoporotic rats.

MATERIALS AND METHODS

We divided a total of 50 female Sprague-Dawley rats into five groups: A (the control group), B and D (the teriparatide group), and C and E (the zoledronic acid group). Following ovariectomy and subcutaneous heparin administration at a dose of 2 IU/kg for four weeks, osteoporosis was created. Groups A, B, and C were fed with standard feed, while Groups D and E were fed with vitamin K-rich feed. After four weeks of treatment, sacrification was performed. The right and left femurs were separated for histopathological and biomechanical evaluation, respectively. For histopathological evaluation, the femurs were decalcified, and the sections were stained with hematoxylin-eosin and evaluated under a light microscope. Fracture healing was evaluated using the classification system as described previously. For biomechanical evaluation, the 3-point stress test and torsion stress test were applied to 10 femurs from each group.

RESULTS

Groups B-E were histopathologically and biomechanically superior to Group A in fracture healing of osteoporotic rats; however, it was not statistically significant (p>0.05). The group that received additional vitamin K was histopathologically and biomechanically superior to the group which was fed with standard feed, although it was not statistically significant (p>0.05).

CONCLUSION

Our study results indicated that both teriparatide and zoledronic acid had beneficial effects on osteoporotic fractures with comparable histological and biochemical results. Vitamin K promoted teriparatide and zoledronic acid treatment on osteoporotic fracture healing. Based on these findings, combination therapies may yield the most optimal results in biomechanical and histological examinations.

Effectiveness of radiofrequency ablation for treatment of plantar fasciitis

Plantar fasciitis is the most common cause of heel pain. Pain can be persistent in some patients and interrupt daily activities and sportive activities. There are a lot of treatment options available for plantar fasciitis. We hypothesized that patients with chronic persistent plantar fasciitis can be successfully treated with radiofrequency nerve ablation (RFNA).Two hundred sixty-one patients with plantar fasciitis (378 feet) treated with RFNA from February 2017 to January 2019 were retrospectively assessed. All the patients had plantar heel pain for at least 6months. Based on their body mass index (BMI), the enrolled patients were divided into obese (BMI ≥ 30kg/m2) and non-obese (BMI < 30kg/m2) groups. The patients were asked to complete a questionnaire just before and after the procedure and during the final follow-up. The BNS Radiofrequency Lesion Generator was used during a single session. The patients' information, including their visual analogue scale (VAS) score and American Orthopaedic Foot and Ankle Society (AOFAS) score, was assessed. During their final follow-up, the patients were asked to rate the success of their treatment by choosing one of the following options: completely successful, very successful, moderately successful, marginally successful, or not successful.The VAS and AOFAS scores of all the patients were evaluated pre-procedure, in the first month after procedure, and during the final follow-up (8-24 months). There was a statistically significant difference between the pre-procedure and postprocedure VAS scores (P < .001), there was no statistically significant difference between the VAS scores in the first month postprocedure and during the final follow-up.There was a statistically significant difference between the pre-procedure and postprocedure AOFAS scores (P < .001), there was no statistically significant difference between the AOFAS scores in the first month postprocedure and during the final follow-up.RFNA can be used as an alternative method to surgical procedures for treating plantar fasciitis because it is safe and effective. The advantages of RFNA are that patients can quickly return to their work and resume weight-bearing activities.

A comparison of double single suture-button fixation, suture-button fixation, and screw fixation for ankle syndesmosis injury: A retrospective cohort study

Different methods have been used throughout the years for syndesmotic injury but there is no consensus on the ideal treatment. Some methods are expensive and some have more complications. The aim of this study is to compare single suture endobutton with double suture endobutton and screw fixation for syndesmotic injury.Sixty nine patients with syndesmotic injury with fibular fractures whom were treated with a single interosseous suture endobutton system (ZipTightTM, Zimmer Biomet), a double interosseous suture endobutton system (ZipTightTM, Zimmer Biomet) and 1 syndesmotic screw (TST, Istanbul, Turkey) were included in this study. Functional and radiological results from patient records between 2015 and 2018 were retrospectively evaluated.Twenty patients were treated with the double interosseous suture endobutton, 23 were treated with the single interosseous suture endobutton, and 26 were treated with traditional AO screw fixation. Three patients from the screw fixation group (11.5%) required revision surgery (P < .05). All the radiologic and clinical outcomes were statistical similar in all 3 groups.Our findings showed that the interosseous suture endobutton system is at least as safe as the screw fixation technique for treatment of syndesmosis joint injuries and can be used as an alternative to the screw method. The interosseous suture endobutton system eliminates the need for a second surgery to remove the hardware, which minimizes the probability of re-diastasis. Since our results showed no statistical difference between single and double interosseous suture endobutton systems, the less costly single endobutton system may be the better alternative.

The Role of the Pie-Crusting Technique of the Medial Collateral Ligament in the Arthroscopic Inside-out Technique for Medial Meniscal Repair With or Without Anterior Cruciate Ligament Reconstruction: A Satisfactory Repair Technique

Purpose

To assess the results of a technique for pie crusting of the medial collateral ligament (MCL) and inside-out medial meniscal repair and perform a comparison with the literature.

Methods

This retrospective study consisted of electronic data collection between 2012 and 2017 with a minimum of 2 years’ follow-up. The inclusion criteria were the presence of difficult medial meniscal tears with joint tightness requiring pie crusting and the presence of acute or chronic tears of zone I or II with or without anterior cruciate ligament reconstruction (ACLR) using hamstring autograft during the same session. The primary outcome of the study was the achievement of good results with the aforementioned technique. There was no control group. All patients underwent assessments at 1, 2, and 6 months in outpatient clinics. At 6 months, the Lysholm knee score was calculated. For statistical analysis, the Social Science Statistics online program was used to perform descriptive analysis and assess any associations between the variables.

Results

This study included 53 patients from a single surgeon’s practice; of these patients, 31 underwent additional ACLR using hamstring autograft during the same session. The mean age was 29.43 years (range, 14-49 years), and the mean increase in the medial joint space width was 3.21 mm (range, 2-5 mm) with pie crusting. At 6 months, the average Lysholm score was 93 (range, 67-100) and the average visual analog scale score was 0.8 (range, 0-4). There was no meaningful association between age, tear pattern, chronicity of tear, joint space width obtained after pie crusting, and associated anterior cruciate ligament tear. Patients returned to their daily activity level at 4.5 months on average and returned to sporting activities at 7.4 months on average. Saphenous nerve symptoms were observed in 5 patients, but no infection or instability was documented in the follow-up period.

Conclusions

In this study, we obtained good outcomes using arthroscopic inside-out medial meniscal repair combined with pie crusting for the release of the MCL, with or without ACLR.

Level of Evidence

Level IV, therapeutic case series.

Effect of cementing on pulmonary arterial pressure in vertebroplasty: A comparison of two techniques

BACKGROUND

Increase in intraosseous pressure and displacement of bone marrow contents leading to fat embolism and hypotension during cement injection in vertebroplasty (VP). We aimed to compare the effect of low and high viscosity cements during VP on pulmonary arterial pressure (PAP) with different cannula.

MATERIALS AND METHODS

Fifty-two patients having multilevel VP due to osteoporotic vertebral compression fractures were randomly treated either by a high viscosity cement (group A, n = 27 patients) and 2.8 mm cannula or a low viscosity cement (group B, n = 25 patients) injected through 4.2 mm cannula. PAP was measured by standard echocardiography and blood d-dimer values were recorded preoperatively, 24 h and third day after operation.

RESULTS

Mean age was 69 (62-87) years in group A and 70 (64-88) years in group B, and sex and comorbidities were similar. Average number of augmented levels was 5.4 in group A and 5.7 in group B. Preoperative mean PAP was 33 mm/Hg in group A, elevated to 41 mm/Hg on first day, and decreased to 36 mm/Hg on third day. The mean PAP in group B was 35 mm/Hg preoperatively, 51 mm/Hg on first day and 46 mm/Hg on third day (p < 0.05). The average blood d-dimer values in group A increased from 2.1 µg/mL to 2.3 µg/mL and in group B from 2.2 µg/mL to 4.2 µg/mL.

CONCLUSION

The finding of this study showed that high viscosity cement injected through a narrower cannula results in lesser PAP increase and d-dimer levels when compared to low viscosity cement injected through a wider cannula. Higher PAP and d-dimer level may show possible thromboembolism. This finding may give spine surgeons to reconsider their choice of cement type and cannula size.

Does the ZipTightTM effective to maintain reduction after the treatment of acute acromioclavicular joint dislocation?

BACKGROUND

The present study evaluated the functional and radiographic outcomes of acute acromioclavicular (AC) joint reconstruction performed using the mini-open technique and a knotless suspensory loop device METHODS:: A total of 25 patients (20 male and 5 female patients; mean age, 30.7 years; standard deviation, 10 years; range, 17-57 years) who fulfilled the inclusion criteria were included in the study. A functional assessment was performed using the Constant and University of California Los Angeles score. The radiologic assessment included standard anterior-posterior views of the AC and coracoclavicular (CC) distances.

RESULTS

The mean follow-up period was 18.6 months (range, 12-23 months). The mean Constant score was 87.2 ± 3.2, and the mean University of California Los Angeles score was 30.1 ± 2.4 at the final follow-up. Radiological evaluation at the last follow-up of the patients: Although there was no statistically significant increase in the AC and CC values of the patients () at the last follow-up, the average CC value in 6 (24%) of the 25 patients was greater than 50% compared with the unaffected side CC and early postoperative CC values. However, there was no statistically significant difference in the Constant and UCLA scores between the 6 patients with reduction loss and the 19 patients with reduction maintenance (P = .86).

CONCLUSIONS

Clinical results of fixation of acute AC joint dislocations using the ZipTight knotless suspensory loop device system and mini-open technique were favorable in terms of functional recovery and pain relief. However, the major disadvantage of this method was radiological loss of AC joint reduction when compared to the contralateral shoulder.

Clinical and radiological outcomes of high tibial osteotomy with combined fixator-assisted nailing and subtubercle tibial osteotomy

OBJECTIVE

The aim of this study was to assess the clinical and radiological results of our high tibial osteotomy technique combining fixator-assisted nailing and subtubercle tibial osteotomy in varus malalignment.

METHODS

This was a retrospective study of a consecutive series of 32 knees in 32 patients ('2 follow-up loss' 12 males and 18 females; mean age at the time of operation: 50.6±7.8 (36-62) years) operated on between 2014 and 2016. Radiographic and clinical measurements were assessed pre- and postoperatively. Kolmogorov-Smirnov, paired t and Wilcoxon rank tests were used in the statistical analyses.

RESULTS

The mean follow-up period was 36.1±8.15 (31-53) months, the mean duration of the hospital stay was 3.6±0.1 (2-6) days, and the mean Kellgren-Lawrence score was 2.4±0.6 (2-4). Time to bony union was an average of 16.17 (12-29) weeks. Compared to the preoperative mechanical medial proximal tibial angle, femorotibial angle and mechanical axis deviation measurements, all the postoperative values showed significant changes (p<0.01). However, there was no statistical difference between the preoperative and postoperative tibial slopes (p>0.05), and the postoperative Caton-Deschamps index did not show a meaningful change (p>0.05). The postoperative visual analog scale, Knee Society Score, and Modified Hospital for Special Surgery Knee Scoring System measures showed significant improvement compared to the preoperative values (p<0.01). The postoperative walking distance increased to 1137.50±845.1 meters, from 359.4±306.2 meters (p<0.01).

CONCLUSION

This percutaneous technique is minimally invasive, corrects the alignment in two planes, and does not affect patellar height. We believe that this technique could be a promising alternative to other knee preserving surgeries in correcting varus malalignment.

LEVEL OF EVIDENCE

Level IV, Therapeutic Study.

The role of drains in adolescent idiopathic scoliosis surgery: Is it necessary?

Close suction drainage systems are widely used in orthopedics and spine surgeries. There are less studies investigating the outcomes of using subfascial closed suction drains in adolescent patients who had undergone idiopathic scoliosis surgery. We evaluated the outcomes of patients with and without closed suction drainage and to investigate whether close suction drainage is needed after adolescent idiopathic scoliosis (AIS) surgery.We retrospectively investigated 63 patients, who underwent posterior spinal surgery for AIS from January 2015 to January 2018. The patients were divided into the following groups: Groups A (drainage group) and B (nondrainage group). We evaluated the wound drainage (wound oozing), need for transfusion, preoperative and postoperative hemoglobin levels, length of hospital stay, and postoperative blood loss from closed suction drains. Patients' scoliosis was categorized according to the Lenke Classification System for Scoliosis. The level of instrumentations was also evaluated.The median postoperative hemoglobin level was lower in group A than in group B. Postoperatively, group A underwent more blood transfusions than group B. Postoperative hospital stay was also significantly longer in group A than in group B. There was no statistical difference in the infection rate between the two groups.Using drains after AIS surgery increases hospital stay duration, blood transfusion rate and patients' anxiety of drain tube removal. Thus, closed suction drainage may not be suitable after AIS surgery.

Vacuum-assisted closure versus moist dressings in the treatment of diabetic wound ulcers after partial foot amputation: A retrospective analysis in 65 patients

PURPOSE

Changes in weight-bearing patterns after partial foot amputations may lead to new localized high-pressure points and keratosis due to ulcerations in patients with neuropathies and hypovascular limbs. As a result, diabetic foot ulcers (DFUs) after partial foot amputations are very complex. The aim of this study was to compare the effectiveness of vacuum-assisted closure (VAC) therapy with conventional moist wound dressings in the treatment of diabetic wound ulcers after partial foot amputations.

METHODS

Sixty-five diabetic patients with a DFU, who had previously undergone partial foot amputation surgery, were assigned to treatment with VAC (group A: 31 patients) or conventional wound moist dressing (group B: 34 patients). The final results were considered as failed treatment if reamputation was required. Conversely, reaching 90% of wound granulation was considered to be a successful endpoint.

RESULTS

The average time to reach 90% granulation tissue was significantly lower in group A (7.8 ± 1.2 weeks vs. 11.1 ± 1.2 weeks; p < 0.001). However, there was no significant difference regarding the reamputation requirements; 38.7% (12 patients) in group A and 41.2% (14 patients) in group B, ( p = 0.839).

CONCLUSION

The results of this study allowed us to conclude that VAC therapy system appears to be an effective treatment for patients with complex DFUs who had previously undergone partial foot amputation.

The effect of mechanical aspiration of the vertebral body on pulmonary arterial pressure before cement injection in the vertebroplasty procedure

PURPOSE

The aim of this study is to compare the efficacy of the mechanical aspiration technique just prior to cement application in the standard vertebroplasty (VP).

METHODS

Forty patients were included in the study. In group A, mechanical aspiration of the cavity was done just before the cement injection and in group B aspiration of vertebral body did not perform, VP was done with the same size cannula, same injection force, same injection speed and same cement viscosity. Pulmonary arterial pressures (PAPs) and blood d-dimer values were recorded preoperatively, 24 h and 3 days after the procedure. The PAP and d-dimer data were statistically compared with Student's t-test.

RESULTS

The mean age was 71 (62-87) in A and 70 (64-88) in B. The augmented level was 6.7 in A and 6.9 in B. Cement leakage was present in four in A and six in B. Acute hypotension was observed immediately after cement injection in one patient in A and four patients in B. The preoperative mean PAP in A was 35mm/Hg and elevated to 48 mm/Hg on the first postoperative day and decreased to 42 mm/Hg on the third postoperative day. The mean PAP in B was 36 mm/Hg preoperatively, 71 mm/Hg on the first day, and 58 mm/Hg on the third day ( p < 0.05). The d-dimer values revealed a difference between groups, the PAP values significantly changed between before and after the operation in both groups ( p < 0.005).

CONCLUSION

Aspiration of the vertebral body can easily be used to decrease the risk of cement leakage and the migration of fatty particles into the pulmonary circulation.

Is pharmacological anticoagulant prophylaxis necessary for adolescent idiopathic scoliosis surgery?

We report the outcomes of mechanical prophylaxis and chemoprophylaxis in patients who underwent elective surgery for idiopathic adolescent scoliosis (AIS).We retrospectively studied the patients who underwent posterior spinal instrumentation for AIS. The patients were divided into three groups: Group A low-molecular-weight heparin (LMWH) started at 8 hours after surgery; Group B LMWH started at 24 hr after surgery; Group C did not receive chemoprophylaxis. The data about wound oozing, need for transfusion, preoperative and postoperative hemoglobin level, length of stay in hospital, interval from the surgery to removal of closed suction drainage tube, postoperative blood loss from closed suction drain, deep venous thrombosis (DVT), and pulmonary embolism (PE) were investigated.The mean age and Lenke classification for all the groups were similar. No DVT or PE was detected in any group. The mean blood loss from the drain was higher in Group A (400 mL) and Group B (450 mL) when compared to Group C (150 mL) (P = .001). There were more wound oozing in Groups A (5) and B (6) than in Group C (3) (P = .585). Three patients in Group B, 3 patients in Group A, and no patient in Group C had superficial infections. However, there was no statistical difference between the groups (P = .182). Postoperative hospital stay was significantly longer in Groups A (6 days) and B (6 days) then in Group C (5 days) (P = .001).Our current study claims that chemoprophylaxis is not necessary for the patients without risk factors after AIS surgery. Early mobilization and mechanoprophylaxis represents adequate prophylaxis in addition to pain management and well hydration in patients' routine treatment. The complications of chemoprophylaxis are not correlated to the initiation time of prophylaxis.

Effect of nonoperative concomitant intraarticular pathologies on the outcome of arthroscopic capsular release for adhesive capsulitis of the shoulder

OBJECTIVE

The aim of this study was to investigate whether coexistent intraarticular lesions are negative prognostic factors for the results of arthroscopic capsular release in frozen shoulder patients.

METHODS

Seventy-two patients who met inclusion criteria and underwent arthroscopic capsular release between March 2011 and August 2015 for the frozen shoulder were retrospectively evaluated. The patients were divided into two groups according to existence of concomitant intraarticular pathologies detected during arthroscopy. Preoperative and postoperative functional results were assessed with Constant score and shoulder ranges of motion; and the amount of pain was evaluated using visual analog scale (VAS).

RESULTS

Group I consisted of 46 patients (mean age 47.2 years and mean follow-up 26 months) without concomitant shoulder pathologies and group II consisted of 26 patients (mean age 48.6 years and mean follow-up 15 months) with coexistent lesions (SLAP lesions, n = 8; SLAP and partial rupture of the RC, n = 4; SLAP, partial rupture of RC and impingement, n = 10; SLAP and impingement, n = 2; and AC arthritis and impingement, n = 2). Preoperatively, the mean ranges of forward flexion (p = 0.221), abduction (p = 0.065), internal rotation (p = 0.564), Constant (p = 0.148) and VAS (p = 0.365) scores were similar between the groups. After a minimum 12 months of follow-up, all patients significantly improved but no statistically significant difference was detected in the mean ranges of forward flexion (152 vs 150; p = 0.902), abduction (137 vs 129; p = 0.095), external rotation (45 vs 40; p = 0.866), internal rotation (5 vs 5 point; p = 0.474), Constant (82 vs 82.3; p = 0.685) and VAS (1.2 vs 1.2; p = 0.634) scores between the groups.

CONCLUSION

The presence of concomitant shoulder pathologies does not appear to affect the clinical outcomes in patients undergoing arthroscopic capsular release for frozen shoulder.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

The effect of N-acetylcysteine on mechanical fatigue resistance of antibiotic-loaded bone cement

BACKGROUND

This biomechanical study evaluates the effect of N-acetylcysteine alone and in combination with the most commonly used antibiotic-loaded bone cement mixtures.

METHODS

We mixed eight bone cement mixture groups including combinations of N-acetylcysteine, gentamicin, teicoplanin, and vancomycin and applied a four-point bending test individually to each sample on days 1 and 15 using an MTS Acumen test device.

RESULTS

The result was less than 50 MPa-the limit declared by the ISO (International Standards Organization)-in only the "gentamicin + bone cement + N-acetylcysteine" group. Mechanical fatigue resistance of the bone cement decreased significantly with the addition of N-acetylcysteine both on day 1 and day 15 (p <  0.001). With the addition of N-acetylcysteine into the "gentamicin + bone cement" and "vancomycin + bone cement" mixtures, a significant decrease in mechanical fatigue resistance was observed both on day 1 and day 15 (p <  0.001). In contrast, with the addition of N-acetylcysteine into the "teicoplanin + bone cement" mixture, no significant difference in mechanical fatigue resistance was observed on days 1 and 15 (p = 0.093, p = 0.356).

CONCLUSION

Preliminary results indicate that adding N-acetylcysteine to teicoplanin-loaded bone cement does not significantly affect the cement's mechanical resistance, potentially leading to a new avenue for preventing and treating peri-prosthetic joint infection. N-acetylcysteine may, therefore, be considered as an alternative agent to be added to antibiotic-loaded bone cement mixtures used in the prevention of peri-prosthetic joint infection.