Clinical and Functional Outcomes of Suture Versus Headless Screw Fixation for Tibial Eminence Fractures in Children

BACKGROUND

Suture and screw fixations are widely used to treat tibial eminence fractures (TEFs). Although a few biomechanical and clinical studies have compared suture fixation (SF) and screw fixation in the treatment of TEFs in children, no comparative clinical studies are available regarding headless screw fixation (HSF).

PURPOSE

To evaluate the clinical and functional outcomes of children with TEF who underwent SF and HSF.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The study included 24 patients treated with either SF (11 patients) or HSF (13 patients) within 1 month of TEF (type 2 or 3) without associated ligamentous and bone injury between 2015 and 2020. All patients were evaluated at a minimum 2-year follow-up in terms of Lysholm score, Tegner activity level, International Knee Documentation Committee subjective score, and isometric strength test. Knee stability was compared based on the Lachman test, pivot-shift test, and KT-1000 arthrometer side-to-side difference.

RESULTS

No significant differences were found between the 2 groups in terms of Lysholm score, Tegner activity level, and International Knee Documentation Committee subjective score at follow-up. All patients were able to resume their daily activities within 6 months after the injury. However, flexion deficits (6°-10°) were found in 2 patients in the SF group and 1 patient in the HSF group, and extension deficits (3°-5°) were found in 3 patients in the SF group and 1 patient in the HSF group, without significant intergroup difference. Stability based on the Lachman test, pivot-shift test, and KT-1000 arthrometer side-to-side difference was also similar between the 2 groups at follow-up. No statistically significant difference was found between the 2 groups in isometric tests performed.

CONCLUSION

The present study is the first to compare the clinical and functional results of SF and HSF techniques. The HSF technique demonstrated comparable clinical and functional outcomes, suggesting its potential as an alternative to the SF technique.

During Arthroscopic Repair of Medial Meniscal Tears: Do Not Be Afraid to Perform "Pie Crust" Technique

In the absence of effective long-term repair of meniscal injuries, damage to the knee may lead to the development of osteoarthritis. Recent reports have recommended meniscal repair to be undertaken in all cases of meniscal tears. However, the most common complication encountered during repair of the medial meniscus is iatrogenic cartilage and meniscal injury due to its unclear visualization. The aim of this study is to evaluate the long-term clinical and radiological results of the pie-crust (PC) technique performed during the repair of medial meniscal tears. This retrospective study included 86 patients who underwent arthroscopic medial meniscus repair. PC technique was performed if the medial joint width was less than 5 mm. The patient population was divided into two groups as who underwent meniscus repair with PC technique (PC + repair group) or not (repair group). All patients were evaluated clinically (Kujala score, International Knee Documentation Committee (IKDC) subjective score, Lysholm score, and Tegner activity score) and radiologically (medial joint width and valgus laxity angle). When the medial joint width measurements before the PC technique and at the postoperative first and sixth months were compared, it was found to be statistically significant (p < 0.05). However, there was no significant difference between the preoperative and 12-month postoperative joint width measurements (p > 0.05). At the 12-month follow-up, no statistically significant difference was determined for the valgus laxity angle in the PC group compared with preoperative values (p > 0.05). The follow-up Kujala score, IKDC subjective score, Lysholm score, and Tegner activity score were similar between the groups. The clinical scores in both groups were determined to have statistically significant increase at 12-month postoperatively compared with the preoperative values (p < 0.05). The results of this study showed that performing the PC technique prior to medial meniscal tear repair increase the medial joint visualization safely and effectively without permanent valgus laxity.

Intramedullary implants coated with cubic boron nitride enhance bone fracture healing in a rat model

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Should We Prefer Magnetic Resonance Imaging to Physical Examination in Meniscal Tears

The aim of this study was to compare the sensitivity, specificity, accuracy, positive and negative predictive values of magnetic resonance imaging (MRI), and clinical examination in the diagnosis of meniscus tears with the findings obtained from the knee joint arthroscopy. A retrospective study was made of 452 patients who underwent knee arthroscopy due to meniscus tears between 2012 and 2017. Physical examination was performed using the Thessaly's, McMurray's, and Joint line tenderness tests (JLTT). On preoperative MRI, medial meniscal tears were observed in 292 patients, lateral meniscal tears in 96 patients, and medial and lateral meniscal tears in 64 patients. According to the arthroscopy results, 284 patients had medial meniscal tears, 108 patients had lateral meniscal tears, and 60 patients had medial and lateral meniscal tears. Sensitivity and specificity of the JLTT was determined as 93 and 86% respectively for medial meniscal tears and 94 and 89% for lateral meniscal tears. The McMurray's test was 60% sensitive, 68% specific for medial meniscal tears (MMT), and 73% sensitive and 68% specific for lateral meniscus tears (LMT). The Thessaly's test was 93% sensitive and 87% specific for medial meniscal tears; and 94% sensitive and 88% specific for LMT. Compared with the arthroscopic findings, MRI was observed to have sensitivity of 94% for MMT and 84% for LMT. For specificity, the values were 89% for MMT and 91% for LMT. Accuracy was 89% for MMT and 86% for LMT. In comparison with the arthroscopic findings, the triple test was determined to have sensitivity of 92% for MMT and 89% for LMT. The specificity was 88% for MMT and 91% for LMT. The results of this study showed that a combination of selected physical examination methods is as sensitive as MRI in the diagnosis of meniscus tears.

Titanium Alloy Intramedullary Nails and Plates Affect Serum Metal Ion Levels within the Fracture Healing Period

Titanium alloy implants are the most used materials for the fixation of lower extremity fractures. Although these implants were thought to be inert materials in vitro, several studies have shown increased serum and remote tissue metal ion levels due to wear of implants and friction of the bone-implant interface in vivo. The aim of this study was to investigate the alteration of serum metal ion levels that are released from intramedullary nails and plates used for the fixation of lower extremity fractures, within the fracture healing period. The study included 20 adult patients, who were treated with intramedullary nail or plate osteosynthesis due to closed lower extremity fractures. Alterations of serum titanium, aluminum, molybdenum, and vanadium levels were evaluated at 6, 12, 18, and 24 weeks postoperatively. A statistically significant increase was determined in serum titanium, aluminum, molybdenum, and vanadium ion levels in the intramedullary nail and plate groups at the end of the follow-up period. Pairwise comparisons of metal ion levels between implant groups revealed no significant difference during a 24-week follow-up period. Compared to the control group, statistically significant increased levels of serum titanium, aluminum, vanadium, and molybdenum ions were determined in the implant groups used for the fixation of lower extremity fractures at the end of 24 weeks. In the current literature, the potential toxic effects of prolonged exposure to low levels of these metal ions are still unknown. It can be predicted that long-term metal ion exposure could result in vivo pathological processes in the future.

Monitoring the Prognosis of Diabetic Foot Ulcers: Predictive Value of Neutrophil-to-Lymphocyte Ratio and Red Blood Cell Distribution Width

The aim of this study was to investigate the prognostic values of neutrophil-to-lymphocyte ratio and red blood cell distribution width in diabetic foot ulcers treatment. A total of 250 adult patients who were treated in our clinic between 2007 and 2018 for diabetic foot ulcers were evaluated retrospectively. Diabetic foot ulcers were divided into 4 groups: major amputation, minor amputation, chronic wound, and complete healing. The mean age of our study groups was 60 years (range = 55-65 years). The mean follow-up period was 28 ± 4.3 months. Neutrophil-to-lymphocyte ratio and red blood cell distribution width cutoff values were determined as 4.3 and 12.1, respectively, for patients in complete recovery group (C sig. = .995 and .871, respectively; P < .05). Neutrophil-to-lymphocyte ratio and red blood cell distribution width cutoff values for patients in the major amputation group were 6.73 and 13.4 (C sig. = .864 and .951, respectively; P < .05), respectively. According to the χ2 comparison of the groups, major amputation was seen in patients with neutrophil-to-lymphocyte ratio >6.3, and complete recovery was seen in patients with neutrophil-to-lymphocyte ratio <4.3. In patients with red blood cell distribution width >13.4, major amputation was found to be significant ( P < .05). According to these results, neutrophil-to-lymphocyte ratio and red blood cell distribution width are inexpensive and easy to access predictive parameters in the diagnosis and follow-up of diabetic foot ulcers.

Surgical treatment of acetabulum posterior wall fractures: Comparison between undercountering and marginal impaction reconstruction method with odd methods

BACKGROUND

Modern treatment principles for posterior wall fractures have become widespread in the last decade in many countries by means of international or local courses. The purpose of this study was to compare the clinical and radiologic outcomes of acetabulum posterior wall fractures using unconventional methods of fixation, including plates placed in unusual directions, or, in the case of reoperation, only interfragmentary screws. In addition, we examined acetabulum posterior wall fractures treated by open reduction and internal fixation with standard undercountered plates from ischion to iliac bone in latter cases.

METHODS

Twenty-one patients who had open reduction and internal fixation of an unstable unilateral fracture of the posterior wall of the acetabulum between 2009 and 2013 were included. Group 1 was composed of 10 former patients who were treated with unconventional methods that included a compression technique with a direct plate or solely screw fixation. Group 2 was composed of latter 11 patients who were treated with standard surgery that included undercountered plates oriented from the ischial tuberosity to the iliac bone proximally and reconstruction of marginal impaction if necessary. The functional outcome was evaluated with the use of the clinical grading system adopted by Merle d'Aubigné and Postel. The Kellgren-Lawrence radiologic criteria were used for the radiologic assessments. The reduction of the fracture, posterior dislocation, marginal impaction, mean fracture particle amount, trochanteric osteotomy and avascular necrosis were compared between the two groups and examined with the Mann-Whitney U test.

RESULTS

In Groups 1 and 2, the median score of the modified Merle d'Aubigné and Postel clinical scoring system was 16 (8-18) and 18 (14-18), respectively. The clinical scores between the two groups were statistically significant (p < 0.01). When two groups were compared using the Kellgren-Lawrence radiographic criteria for the development of osteoarthritis, the median value in Groups 1 and 2 was 3 (0-4) and 1 (0-3), respectively (p < 0.01).

CONCLUSIONS

This study displays the evolution of the surgical treatment of acetabular fractures of the posterior wall in our clinic. The older methods failed in terms of exposure, diagnosis of fracture anatomy and fixation techniques. Patients treated after the surgeons took courses in this field showed evidence of superior clinical and radiological scores. We attribute these benefits to exposure, definition and treatment of marginal impaction and fixation principles.

The Role of Biplanar Distal Locking in Intramedullary Nailing of Tibial Shaft Fractures

BACKGROUND

To compare the union times of the uncomplicated tibial shaft fractures, which were distally locked by two coronal and one sagittal screws and by only two coronal screws.

METHODS

45 patients with tibial shaft treated with intramedullary nailing included in this study. 23 of 45 fractures were treated with uniplanar two distal interlocking (Group 1) and 22 fractures were treated with biplanar three distal interlocking (Group 2). Patients with closed fractures treated by closed nailing and having a full set of radiographs on PACS system was included. Fracture unions were evaluated by two authors.

RESULTS

Union time was significantly shorter in biplanar distal interlocking group (Group 2) compared to uniplanar distal interlocking group (Group 1) (P=0.02). Mean union time in groups 1 and 2 were 14.63±4.5 and 10.77±3.0 weeks, respectively .When only distal third tibial shaft fractures were evaluated, Group 2 [11.2±3.1 weeks (n:17)] had significantly lower union time compared to Group 1 [15.07±4.8 weeks (n:14)] (P=0.01). Inter-observer reliability for fracture union times was high with rho= 0.89 with SE of 0.51 (P<0.001).

CONCLUSION

Biplanar distal interlocking procedure had a significantly shorter union time. Biplanar distal interlocking procedure allows a faster fracture union probably because of a more stable fixation construct.

Biomechanical comparison of three different fixation techniques for anterior column posterior hemitransverse acetabular fractures using anterior intrapelvic approach

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.