Acta Orthopaedica Et Traumatologica Turcica[JOURNAL]
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200 papers
Comparative evaluation of large language model-based chatbots in a septic arthritis scenario: ChatGPT, Claude, and Perplexity.
Bayrak HC, Karagöz B, Bayrak Ö
Acta Orthop Traumatol Turc · 2025 Oct · PMID 41578826 · Full text
OBJECTIVE: This study aimed to comparatively evaluate the clinical knowledge generation performance of 3 widely used large language model (LLM)-based chatbots (ChatGPT, Claude, and Perplexity) in the context of septic ar...
OBJECTIVE: This study aimed to comparatively evaluate the clinical knowledge generation performance of 3 widely used large language model (LLM)-based chatbots (ChatGPT, Claude, and Perplexity) in the context of septic arthritis. METHODS: This cross-sectional comparative study was based on 24 scenario-based clinical questions developed in accordance with the SANJO guideline (Management of Septic Arthritis in Native Joints) of the European Bone and Joint Infection Society. Responses generated by ChatGPT (OpenAI GPT-4), Claude 2 (Anthropic), and Perplexity AI were independently assessed by 2 senior experts: 1 in orthopedic surgery and the other in infectious diseases. Each response was evaluated across 6 domains: scientific accuracy, content depth, termino logical consistency, clinical applicability, brevity, and reference support, using a 5-point Likert scale. RESULTS: All 3 LLM-based chatbots achieved perfect scores in accuracy and terminological consistency (P = 1.000), and no significant dif ference was observed in clinical applicability (P = .912). Perplexity scored significantly lower in content depth compared to both ChatGPT (P = .001) and Claude (P = .041), whereas ChatGPT and Claude did not differ significantly (P = .807). ChatGPT produced significantly more unnecessary elaboration than Claude (P = .009) and Perplexity (P < .001), while Claude and Perplexity were comparable (P = .115). For reference support, Perplexity scored significantly higher than both ChatGPT (P < .001) and Claude (P < .001), with no difference between the latter 2 (P = 1.000). Overall, Perplexity achieved the highest total score (P < .001), followed by ChatGPT and Claude. Interrater agree ment was substantial (κ = 0.72). CONCLUSION: The LLM-based chat platforms demonstrated overall high performance, but their strengths differed across evaluation domains. While ChatGPT and Claude provided more comprehensive and detailed responses, Perplexity offered stronger reference sup port. These findings suggest that context-specific selection of LLMs is essential, as the optimal choice may vary depending on whether detailed explanation or robust referencing is prioritized. Cite this article as: Bayrak HC, Karagöz B, Bayrak Ö. Comparative evaluation of large language model-based chatbots in a septic arthritis scenario: ChatGPT, Claude, and Perplexity. Acta Orthop Traumatol Turc., 2025;59(6):415-420.
Minimally invasive (ring forceps) versus open Achilles tendon repair: A retrospective comparison of ultrasonographic and functional outcomes.
Yigit O, Karacaatli Erdogan M, Canbaz SB … +4 more , Ozgur EG, Unsalan O, Igrek S, Eceviz E
Acta Orthop Traumatol Turc · 2025 Dec · PMID 41578823 · Full text
OBJECTIVE: While surgical repair is standard for acute Achilles tendon ruptures, the optimal technique remains debated. This study com pares clinical, functional, and ultrasonographic outcomes between minimally invasive...
OBJECTIVE: While surgical repair is standard for acute Achilles tendon ruptures, the optimal technique remains debated. This study com pares clinical, functional, and ultrasonographic outcomes between minimally invasive and open surgical approaches, with particular focus on: (1) patient-reported recovery, (2) tendon healing dynamics, and (3) the utility of ultrasound in postoperative monitoring. METHODS: This retrospective study analyzed 108 consecutive patients undergoing surgical repair for acute Achilles tendon ruptures between 2015-2023, comparing minimally invasive (n = 58; ring forceps technique) and open approaches (n = 50; Krackow technique). Functional outcomes were assessed using American Orthopaedic Foot and Ankle Society (AOFAS), Patient-Reported Outcomes Measurement Information System (PROMIS), and Madrid Sonographic Enthesitis Index (MASEI) scores at standardized 6-, 12-, and 24-month follow-ups, while ultrasonographic evaluations quantified tendon thickness at rupture and insertion sites relative to contralat eral tendons. Complication rates and demographic variables were systematically reviewed, with all patients receiving identical postoper ative rehabilitation protocols. RESULTS: A total of 108 patients were included in the study, with a mean age of 41.56 ± 13.98 years (range, 18-68). Minimally invasive sur gery was performed in 58 patients (53.7%), while the remaining 50 patients (46.3%) underwent open surgical repair. The mean follow-up duration was 2.4 years (minimum of 2 years of follow-up). Patients in the minimally invasive group reported significantly higher PROMIS scores compared to those in the open surgery group (P < .001). However, no significant differences were observed in AOFAS or MASEI scores between the groups (P > .05). Ultrasonographic evaluation revealed that the mean tendon thickness at the rupture site was signifi cantly greater in the minimally invasive group (1.04 cm; range, 0.93-1.15) than in the open surgery group (0.87 cm; range, 0.77-0.93) (P < .001). Furthermore, the operated-to-intact tendon thickness ratio was 2.13 in the minimally invasive group and 1.78 in the open surgery group, which was also statistically significantly different (P = .006). CONCLUSION: Minimally invasive achilles tendon repair was associated with potential advantages compared to open techniques, includ ing more favorable patient-reported outcomes (median PROMIS score 80 vs. 76, P < .001), increased tendon thickness (19% greater, P < .001), a potential indicator of differential healing patterns, and lower wound complication rates, while importantly achieving equivalent high-level function as measured by the AOFAS and MASEI scores. The main limitations of this study include its retrospective design and the potential for unmeasured confounding. Ultrasound serves as a critical postoperative tool, objectively quantifying healing progression and informing return-to-sports decisions. These findings suggest potential advantages of minimally invasive approaches and support their consideration as a viable alternative to open repair in selected patients; however, the choice of technique should be individualized based on surgeon experience and patient-specific factors. However, these associative findings require validation in randomized trials. Cite this article as: Yigit O, Erdogan MK, Canbaz SB, et al. Minimally invasive (ring forceps) versus open achilles tendon repair: A retrospective comparison of ultrasonographic and functional outcomes. Acta Orthop Traumatol Turc., 2025;59(6):394-404.
A novel atlantoaxial subluxation fixation technique combining transarticular screws with transverse rod and Gallie's wires: A report of two cases.
Chandirasegaran S, Vnr GP, Chan CYW … +1 more , Kwan MK
Acta Orthop Traumatol Turc · 2025 Oct · PMID 41578821 · Full text
The atlantoaxial segment of the cervical spine is unique for its distinctive anatomical features. Given the variation in the anatomy of this region, surgeons must possess a profound knowledge of its anatomy to be able to...
The atlantoaxial segment of the cervical spine is unique for its distinctive anatomical features. Given the variation in the anatomy of this region, surgeons must possess a profound knowledge of its anatomy to be able to combine multiple surgical approaches tailored to the specific anatomical variants of the patient's condition. Insertion of C1 lateral mass screws can be technically demanding, particularly in cases where dissection leads to iatrogenic injury of the C1/C2 venous sinus and causes significant bleeding or in patients with dysplastic C1 anatomy or vertebral artery anomalies. Gallie's fusion necessitates an intact posterior arch and C2 spinous process for the wire place ment. However, this technique carries a risk of C2 spinous process fracture, which may compromise the overall stability of the construct. Magerl's transarticular screw technique is an option, but it requires the reduction of the C1/C2 subluxation before the screws can be placed. In this report, a novel surgical technique that combines transarticular screws with a transverse rod and Gallie's wire fixation utilized in 2 cases of atlantoaxial subluxation is illustrated. This technique will be an alternative option of C1-C2 fixation, which mitigates the surgical difficulties of the existing techniques while enhancing the stability of the construct. Cite this article as: Chandirasegaran S, Praveen G, Chan C.Y.W, Kwan M.K. A novel atlantoaxial subluxation fixation technique combining transarticular screws with transverse rod and Gallie's wires: A report of two cases. Acta Orthop Traumatol Turc., 2025;59(6):493-496.
Histopathological and biomechanical effects of papaverine application in rotator cuff tendinopathy treatment: An experimental rat model study.
Çelebiıt ME, Meydaneri S, Çakmak O
Acta Orthop Traumatol Turc · 2025 Nov · PMID 41578820 · Full text
OBJECTIVE: This study aimed to evaluate the histopathological and biomechanical effects of intraperitoneal (systemic) and locally applied Papaverine on tendon healing in a rat rotator cuff model in which collagenase - in...
OBJECTIVE: This study aimed to evaluate the histopathological and biomechanical effects of intraperitoneal (systemic) and locally applied Papaverine on tendon healing in a rat rotator cuff model in which collagenase - induced tendinopathy was induced. METHODS: Twenty-four adult male Sprague-Dawley rats were randomly allocated into three groups: Group 1 (control), Group 2 (local papav erine application), and Group 3 (intraperitoneal papaverine application). Supraspinatus tendinopathy was induced by surgical injection of Type I collagenase. Group 2 received local papaverine at the surgical site, while Group 3 received systemic intraperitoneal papaverine. On day 30, the rats were sacrificed, and shoulder tissues were harvested for histopathological and biomechanical analysis. RESULTS: Histopathological evaluation revealed no significant differences among the groups regarding fiber structure, cellularity, or vascularity (P > .05). In contrast, biomechanical analysis demonstrated that the local papaverine group showed statistically significant superiority over the other groups in tendon breaking force, elongation, and durability (P < .0001). CONCLUSION: Local application of papaverine improved the biomechanical durability of tendon tissue, although no significant histopatho logical differences were observed. These findings suggest that papaverine may contribute to regenerative processes and could serve as a supportive agent in the treatment of rotator cuff tendinopathy. However, further studies are required to confirm its clinical applicability. Cite this article as: Çelebi ME, Meydaneri S, Çakmak O. Histopathological and biomechanical effects of papaverine application in rotator cuff tendinopathy treatment: An experimental rat model study. Acta Orthop Traumatol Turc., 2025;59(6):428-433.
Soft tissue recurrence in giant cell tumor of bone: Risk factors and radiological and histopathological features.
Mirioğlu A, Dalkır KA, Ölke HC … +4 more , Kundakçı B, Bağır M, Eren K, Deveci MA
Acta Orthop Traumatol Turc · 2025 Dec · PMID 41578816 · Full text
OBJECTIVE: Giant cell tumor of the bone (GCTB) is a locally aggressive benign tumor with unpredictable recurrence patterns. While intraos seous recurrences are well-documented, soft tissue recurrence (STR) remains underr...
OBJECTIVE: Giant cell tumor of the bone (GCTB) is a locally aggressive benign tumor with unpredictable recurrence patterns. While intraos seous recurrences are well-documented, soft tissue recurrence (STR) remains underrecognized. This study aimed to identify risk factors, radiographic features, and histopathological characteristics associated with STR of GCTB. METHODS: This retrospective study included 69 patients treated for GCTB between 1996 and 2022. Demographic data, tumor location, surgical method, recurrence history, and adjuvant treatments were extracted from medical records. Radiologic assessments were performed using a picture archiving and communication system, and lesions were graded by Campanacci classification. analysis was performed using chi-square, Fisher's exact, and Mann-Whitney U-tests. RESULTS: The initial surgical approach was curettage in 55 patients (79.7%), resection in 14 (20.3%). Recurrence occurred in 24 patients (34.8%), and STR was identified in 7 (10.1%). Most STRs were located near the distal femur. Among these, 4 had prior intraosseous recur rence, and 5 had Campanacci grade 3 lesions. No statistically significant association was found between STR and variables including age, sex, tumor volume, Campanacci grade, tumor location, denosumab, or local adjuvant use. H3F3A analysis was performed in 6 out of 7 patients with STR, and positivity was detected in 3 of them. Pulmonary metastasis was documented in 8 patients overall, including 3 of 7 with STR (42.9%) compared with 5 of 62 without STR (8.1%), representing a significant difference. CONCLUSION: Soft tissue recurrence in GCTB may occur independently or following intraosseous recurrence and is frequently observed in high-grade lesions. Although not statistically significant, the findings suggest a possible association between tumor aggressiveness and STR. Histological features remain consistent with osseous lesions, but the diagnostic value of H3F3A expression in STRs warrants fur ther investigation. Importantly, STR represents a distinct recurrence pattern and may be associated with an increased risk of pulmonary metastasis, underscoring the need for vigilant long-term follow-up and systematic surveillance. Cite this article as: Mirioğlu A, Dalkır KA, Ölke HC, et al. Soft tissue recurrence in giant cell tumor of bone: risk factors and radiological and histopathological features. Acta Orthop Traumatol Turc., 2025;59(6):470-476.
In silico assessment of talus osteochondral lesion size and location on biomechanical load distribution using tilted talar dome planes.
Aslan L, Subasi O, Karaismailoglu B … +4 more , Gedik CC, Yuruk B, Esfahani SA, Eren I
Acta Orthop Traumatol Turc · 2025 Dec · PMID 41578813 · Full text
OBJECTIVE: This study aimed to computationally evaluate the effects of lesions of varying sizes and locations on stress distribution and ankle stiffness across the nine-zone grid of the talar dome in three different ankl...
OBJECTIVE: This study aimed to computationally evaluate the effects of lesions of varying sizes and locations on stress distribution and ankle stiffness across the nine-zone grid of the talar dome in three different ankle positions. METHODS: An adult ankle geometry was modeled with 1 mm of cartilage on both sides of the tibiotalar contact. Lesions with diameters of 4.5, 6.4, and 9 mm were created on the talar dome at each grid partition, ranging from section 1 (anteromedial) to 9 (posterolateral). The key innovation of the study was the use of tilted talar planes to account for the dome's curvature, enabling more accurate lesion model ing and biomechanical analysis. Percent changes in osteochondral von Mises stress distribution and ankle stiffness parameters were investigated using finite element analysis. Based on the designated design parameters, 81 different cases were modeled and simulated. RESULTS: Zones 7 (posteromedial, -33.2% change in stiffness for a 9 mm defect), 3 (anterolateral, -24.2% change in stiffness for a 9 mm defect), and 8 (mid-posterior, -48.8% change in stiffness for a 9 mm defect) were found to be the most critical zones, showing evidence of decreased ankle stiffness in neutral, dorsiflexion, and plantarflexion positions, respectively. Zone 9 (posterolateral; neutral -4.7%, dorsi flexion 5.4%, plantarflexion 0.17% stiffness change for a 9 mm defect) was found to be the least critical zone in terms of biomechanical stiffness. CONCLUSION: From a clinical standpoint, since lesions in zones 8, 7, and 3 significantly impact joint biomechanics compared to other zones, more aggressive cartilage restoration or augmentation could be required while lesions in less problematic zones like zone 9 can be treated withmicrofracture surgery. Cite this article as: Aslan L, Subasi O, Karaismailoglu B, et al. In silico assessment of talus osteochondral lesion size and location on biomechanical load distribution using tilted talar dome planes. Acta Orthop Traumatol Turc., 2025;59(6):361-367.
The relationship between preoperative relative second metatarsal length and postoperative transfer metatarsalgia following hallux valgus surgery.
Karagoz B, Bayrak HC, Dincer DE
Acta Orthop Traumatol Turc · 2025 Dec · PMID 41578810 · Full text
OBJECTIVE: This study aimed to investigate the potential association between transfer metatarsalgia, a complication that may arise post operatively following hallux valgus surgery, and the preoperative relative second me...
OBJECTIVE: This study aimed to investigate the potential association between transfer metatarsalgia, a complication that may arise post operatively following hallux valgus surgery, and the preoperative relative second metatarsal length measured on weight-bearing radio graphs. Additionally, it was sought to evaluate the predictive value of this radiographic parameter. METHODS: A total of 126 patients who underwent primary hallux valgus surgery between January 2022 and December 2023 and had a minimum follow-up of 12 months were retrospectively reviewed. Patients were categorized into 2 groups based on the presence or absence of transfer metatarsalgia during the postoperative follow-up. Relative second metatarsal length was measured as the primary radiographic variable using preoperative weight-bearing anteroposterior foot radiographs. In addition, the hallux valgus angle (HVA) and the intermetatarsal angle (IMA) were evaluated preoperatively. Clinical outcomes were assessed using the American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal (AOFAS Hallux MTP-IP) score at the 12-month follow-up. Demographic and surgical variables, such as age, sex, surgical technique, and implant type, were also recorded. Group comparisons were performed, and multivariate logistic regression and receiver operating characteristic (ROC) curve analyses were conducted to identify variables predictive of transfer metatarsalgia. RESULTS: Patients who developed transfer metatarsalgia had significantly higher preoperative relative second metatarsal length values (P < .001). Among the variables included in the multivariate logistic regression model, only relative second metatarsal length was found to be a statistically significant predictor of transfer metatarsalgia (odds ratio: 5.176; 95% CI: 2.813-9.493). Receiver operating characteristic curve analysis identified a threshold value of 2.15 mm, which was adopted as 2 mm for clinical applicability, with an area under the curve of 0.832, sensitivity of 79.4%, and specificity of 78.2%. In contrast, other parameters such as age, sex, surgical technique, implant type, preoperative HVA, IMA, and postoperative AOFAS Hallux MTP-IP scores were not significantly associated with the development of transfer metatarsalgia. CONCLUSION: Relative second metatarsal length was found to be significantly associated with the development of postoperative transfer metatarsalgia, and ROC analysis identified 2 mm as a clinically applicable cutoff value. Preoperative measurement of relative second metatarsal length can help identify patients at higher risk of this complication, allowing for improved patient counseling and more informed surgical planning. Cite this article as: Karagoz B, Bayrak HC, Dincer DE. The relationship between preoperative relative second metatarsal length and postoperative transfer metatarsalgia following hallux valgus surgery. Acta Orthop Traumatol Turc., 2025;59(6):387-393.
The effect of electrical bone stimulation on bone union in foot and ankle injuries: A scoping review.
Schluter R, McLeod H, Ebrahimi A … +5 more , Subasi O, Gedik CC, Aslan L, Ashkani-Esfahani S, Kwon JY
Acta Orthop Traumatol Turc · 2025 Dec · PMID 41578809 · Full text
OBJECTIVE: This study aimed to evaluate the reported efficacy of electrical bone stimulation (EBS) in promoting union in foot and ankle fractures and arthrodesis by synthesizing the available literature. METHODS: A liter...
OBJECTIVE: This study aimed to evaluate the reported efficacy of electrical bone stimulation (EBS) in promoting union in foot and ankle fractures and arthrodesis by synthesizing the available literature. METHODS: A literature review was conducted using PubMed/Medline, EMBASE, ScienceDirect, Web of Science, and CINAHL. Study type, patient demographics, interventions, and outcomes were extracted. The Methodological Index for Non-Randomized Studies assessment tool was used for methodological quality assessment and for evaluating outcomes regarding union rates. RESULTS: Fourteen studies involving 1253 patients met inclusion criteria from a total of 668 screened articles. These studies involved 1253 patients treated with EBS for foot and ankle fracture and fusion surgeries. The majority of investigations reported increased success unionization and reduced time to union using EBS methods including direct current, capacitated coupling, pulsed electromagnetic field (PEMF), low-intensity pulsed ultrasound (LIPUS), and combined magnetic field. CONCLUSION: Although existing evidence suggests that EBS may enhance union rates, there is no consensus regarding the most effective stimulation modality due to limited comparative data. Emerging modalities such as PEMF and LIPUS demonstrate promising results; however, well-designed comparative studies are needed to clarify their relative efficacy and safety profiles. Cite this article as: Schluter R, McLeod H, Ebrahimi A, et al. The effect of electrical bone stimulation on bone union in foot and ankle injuries: A scoping review. Acta Orthop Traumatol Turc., 2025;59(6):349-360.
Cemented versus cementless hemiarthroplasty in end-stage chronic kidney disease: A retrospective comparative study of femoral neck fracture outcomes.
Abul MS, Yılmaz H, Sevim ÖF … +3 more , Hekim Ö, Kayaalp ME, Eceviz E
Acta Orthop Traumatol Turc · 2025 Oct · PMID 41578806 · Full text
OBJECTIVE: This study aimed to compare the functional outcomes and complications of cemented versus cementless femoral stem fixation in end-stage chronic kidney disease (CKD) patients with traumatic femoral neck fracture...
OBJECTIVE: This study aimed to compare the functional outcomes and complications of cemented versus cementless femoral stem fixation in end-stage chronic kidney disease (CKD) patients with traumatic femoral neck fractures (FNF). METHODS: This retrospective cohort study included 43 hips of 42 patients with end-stage chronic kidney disease (mean age 77.7 years; range, 55-89; 42.9% female) who underwent hemiarthroplasty for traumatic femoral neck fractures at a regional trauma center between 2010 and 2022. Patients were divided into two groups according to the fixation method: cemented hemiarthroplasty (n = 23) and cement less hemiarthroplasty (n = 20). Functional outcomes were assessed using the Harris Hip Score (HHS), and complications including throm boembolic events, surgical site infection, periprosthetic fracture, prosthesis dislocation, osteolysis, reoperation, and mortality were evaluated. RESULTS: The mean follow-up duration was 45.1 months. At final follow-up, the mean HHS was significantly higher in the cementless group compared with the cemented group (72.1 vs. 68.3, P = .011). Osteolysis occurred more frequently in the cemented group (30.4% vs. 0%, P = .008). No statistically significant differences were observed between the groups regarding thromboembolic events (0% vs. 5.0%, P = .284), surgical site infection (4.3% vs. 10.0%, P = .473), periprosthetic fracture (4.3% vs. 0%, P = .351), prosthesis dislocation (8.7% vs. 5.0%, P = .639), reoperation rates (13.0% vs. 15.0%, P = .855), or overall mortality (69.6% vs. 60.0%, P = .517). CONCLUSION: In end-stage CKD patients with traumatic FNFs, cementless hemiarthroplasty was associated with fewer cases of osteolysis and better functional outcomes compared with cemented fixation. These findings highlight the potential biomechanical advantage of cementless fixation in prolonging prosthesis survival and support its consideration as the preferred option in patients with end-stage CKD. Cite this article as: Abul MS, Yılmaz H, Sevim ÖF, Hekim Ö, Kayaalp ME, Eceviz E. Cemented versus cementless hemiarthroplasty in end-stage chronic kidney disease: A retrospective comparative study of femoral neck fracture outcomes. Acta Orthop Traumatol Turc., 2025;59(6):458-462.
Radial head arthroplasty provides successful long-term results in patients treated for comminuted fractures of the radial head, minimum eight-year follow-up.
Gedikbaş M, Aşcı M, Eren MB … +1 more , Güneş T
Acta Orthop Traumatol Turc · 2025 Nov · PMID 41578804 · Full text
OBJECTIVE: This study aimed to evaluate the long-term results of radial head arthroplasty (RHA) in treating comminuted radial head fractures (RHF). METHODS: Patients who underwent surgery for RHF using the RHA method bet...
OBJECTIVE: This study aimed to evaluate the long-term results of radial head arthroplasty (RHA) in treating comminuted radial head fractures (RHF). METHODS: Patients who underwent surgery for RHF using the RHA method between 2011 and 2018 were retrospectively analyzed. We included patients who received reconstruction with a radial head prosthesis in the acute or chronic phase due to a comminuted radialhead fracture. Patients were excluded if they had a systemic concomitant disease, a previous infection, a fracture or surgery on the same elbow, osteoarthritis, or a follow-up period of less than 5 years. Fractures were classified according to the Mason classification system. For functional assessment, postoperative evaluations included range of motion (ROM), the Mayo Elbow Performance Score (MEPS), and the Quick Disabilities of the Arm, Shoulder, and Hand score (qDASH). RESULTS: Thirty-five patients (23 male, 12 female) were included in the study. Twenty-five had Mason Type III fractures, and 10 had Mason Type IV RHF. The mean age was 47.8 ± 15.6 years, and the mean follow-up period was 117.3 ± 9.3 months. The mean MEPS was 87.5 ± 10.3, and the mean qDASH score was 16.7 ± 10.8. Patients with Mason Type III RHF demonstrated greater flexion (140° vs. 112.5°) and a larger rotational arc of motion (155.5° vs. 144.9°) compared to those with Mason Type IV fractures. However, extension loss, MEPS, and qDASH scores were comparable between the groups. Radiological outcomes and complication rates also showed no significant differences between fracture types. CONCLUSION: The findings of this study indicate that RHA is an effective treatment option for nonreconstructable RHF, offering reliable pain relief, restoration of elbow mobility, and quality of life. These outcomes highlight its value in managing patients with poor prognostic factors, where conventional reconstruction is not feasible, and in preventing long-term functional impairment. Cite this article as: Gedikbaş M, Aşcı M, Eren MB, Güneş T. Radial head arthroplasty provides successful long-term results in patients treated for comminuted fractures of the radial head, minimum eight-year follow-up. Acta Orthop Traumatol Turc., 2025;59(6):439-445.
Hip and knee arthroplasty in solid organ transplant patients: Results from a Turkish government-based health registry.
Yılmaz MK, Hakyemez ÖS, Birinci M … +6 more , Bingöl İ, Ata N, Ülgü MM, Birinci Ş, Azboy I, Erdoan F
Acta Orthop Traumatol Turc · 2025 Nov · PMID 41578796 · Full text
OBJECTIVE: This national database study of a large cohort aimed to investigate the mortality and complication rates of patients with a his tory of solid organ transplantation (SOT) who underwent total knee arthroplasty (...
OBJECTIVE: This national database study of a large cohort aimed to investigate the mortality and complication rates of patients with a his tory of solid organ transplantation (SOT) who underwent total knee arthroplasty (TKA), total hip arthroplasty (THA), or hemiarthroplasty (HA). Additionally, this study aimed to identify predictive factors for medical and surgical complications as well as mortality in this patient population. METHODS: This cohort study utilized data from the Turkish Ministry of Health to assess SOT patients undergoing TKA, THA, and HA. Propensity score matching was applied to create a comparable control group. Primary endpoints included medical and surgical complica tions within 90 days and mortality rates (in-hospital, at 1 month, 3 months, 1 year, and overall). RESULTS: Kidney transplantation was the most common type of transplant (n = 666, 81.5%), followed by liver transplantation (n = 101, 12.4%). Revision rates were 4.5% in the SOT group and 3.9% in the control group (P = 0.472). SOT patients exhibited higher rates of medical complications, including chronic renal failure, pneumonia, electrolyte imbalances, urinary complications, and transfusion needs (P < 0.001). Mechanical complications were less frequent in the SOT group (2.57%) compared to the control group (3.7%), but prosthetic joint infection (PJI) rates were higher (2.57% vs. 1.4%, P = 0.035). Fracture history (HR: 4.82, 95% CI: 1.66-13.97, P = 0.004), chronic obstruc tive pulmonary disease (HR: 1.7, 95% CI: 1.17 2.46, P = 0.005), and age (HR: 1.034, 95% CI: 1.01-1.05, P < 0.001) were identified as indepen dent predictors of 90-day mortality. Patients undergoing HA experienced significantly higher mortality compared to TKA and THA (17.5%, 1.1%, and 1.7%, respectively; P < 0.001). CONCLUSION: SOT patients undergoing joint arthroplasty have elevated risks of complications and mortality, particularly in the presence of fractures. Multidisciplinary management, perioperative optimization of modifiable comorbidities, and close monitoring may help mitigate these risks and improve patient outcomes. Cite this article as: Kürşat Yılmaz M, Serdar Hakyemez Ö, Birinci M, et al. Hip and knee arthroplasty in solid organ transplant patients: results from a Turkish government-based health registry. Acta Orthop Traumatol Turc., 2025;59(6):452-457.
Increases in suture purchase of same magnitude lead to a higher gap resistance force for barbed sutures used in flexor tendon repair.
Cırdı YU, Günay AE, Ekici M … +3 more , Şekerci ÖT, Ozturk Rİ, Gürsoy S
Acta Orthop Traumatol Turc · 2025 Dec · PMID 41578793 · Full text
OBJECTIVE: There is still no optimal suture material or configuration for flexor tendon repair. Barbed sutures provide an alternative for flexor tendon repair with unidirectional clefts that effectively resist sliding. I...
OBJECTIVE: There is still no optimal suture material or configuration for flexor tendon repair. Barbed sutures provide an alternative for flexor tendon repair with unidirectional clefts that effectively resist sliding. Increasing the suture purchase results in an expected increase in the tensile force. This study investigated the relationship between suture purchase length and repair strength in flexor tendon. This addresses the question of whether it is possible to achieve sufficient tensile strength compared to a 2-strand polypropylene suture by simply increasing the barbed suture course inside the tendon. METHODS: The study involved 24 sheep flexor digitorum tendons, which were divided into 4 subgroups, each comprising 6 tendons. Group P1 utilized polypropylene sutures 1 cm from the incision, while group P2 used it 2 cm away. Group B1 utilized a barbed suture positioned 1 cm from the incision, while group B2 employed a barbed suture 2 cm from the incision. The outcome measures included testing for 2-mm Gap Resistance (2mm-GR) and maximum tensile strength (MTS) using an Instron® 3345K7023 tensile testing device (Norwood, MA, USA). RESULTS: A 2 cm suture purchase length increased by the mean 2mm-GR by 6.9 N for polypropylene and 12.6 N for barbed sutures. Group B2 showed the highest 2mm-GR (20.7 N). Groups P2 and B2 had significantly higher 2mm-GR than groups P1 and B1 (P < .05). The MTS did not differ significantly between the groups (P = .743). Suture breakage occurred in 92% of cases, with knot failure observed in 8%. CONCLUSION: Extending the purchase length of the barbed suture within the tendon significantly enhances the MTS and 2mm-GR. With further refinement, barbed sutures have the potential to become a favorable option for tendon repair, possibly facilitating early and effec tive postoperative rehabilitation. Cite this article as: Cırdı YU, Günay AE, Ekici M, Şekerci ÖT, Ozturk Rİ, Gürsoy S. Increases in suture purchase of same magnitude lead to a higher gap resistance force for barbed sutures used in flexor tendon repair. Acta Orthop Traumatol Turc., 2025;59(6):434-438.
Effect of asymmetric anterior and posterior wedge openings on medial and lateral posterior tibial slope in medial open wedge high tibial osteotomy: An in vitro study on sheep tibias.
Yahyaoğlu A, Ergün S, Eceviz E
Acta Orthop Traumatol Turc · 2025 Oct · PMID 41578792 · Full text
OBJECTIVE: This study aimed to evaluate the effects of different anterior and posterior wedge opening distances on medial and lateral pos terior tibial slope (PTS) angles during medial open wedge high tibial osteotomy (M...
OBJECTIVE: This study aimed to evaluate the effects of different anterior and posterior wedge opening distances on medial and lateral pos terior tibial slope (PTS) angles during medial open wedge high tibial osteotomy (MOWHTO) using an in vitro sheep tibia model. METHODS: This in vitro study was conducted on 24 tibial bones from 2-year-old female domestic sheep. The samples were divided into 2 groups (n = 12 each) based on wedge configuration. Group 1 underwent osteotomy with a posterior opening of 6 mm and an anterior of 2 mm to reduce slope, while Group 2 received a 2 mm posterior and 6 mm anterior gap to increase slope. The medial and lateral PTS angles were measured separately using true lateral radiographs before and after osteotomy. Rotational changes were evaluated on computed tomography. Nine tibiae were excluded due to lateral hinge fractures; thus, the final analysis included 7 samples in Group 1 and 8 in Group 2. RESULTS: In Group 1, the lateral PTS decreased significantly more than the medial PTS (6.28° ± 2.5 vs. 1.49° ± 1.9, P = .03). In Group 2, medial and lateral PTS changes were similar (5.28° ± 2.8 vs. 5.76° ± 2.9, P = .79). Computed tomography images revealed that the hinge was intact in the anterolateral cortex in Group 1 (Fig 5a) and in the lateral cortex in Group 2. Rotational assessment showed external rotation of the proximal fragment in Group 1 (2.05° ± 1.38) and internal rotation in Group 2 (Fig 5b) (2.88° ± 1.62), with no significant difference between groups (P = .33). CONCLUSION: In MOWHTO, applying a larger posterior opening than anterior results in greater lateral PTS reduction compared to the medial side, particularly when the hinge is located in the anterolateral cortex. These findings highlight the importance of wedge configura tion and hinge integrity in controlling sagittal plane alignment. Cite this article as: Yahyaoğlu A, Ergün S, Eceviz E. Effect of asymmetric anterior and posterior wedge openings on medial and lateral posterior tibial slope in medial open wedge high tibial osteotomy: An in vitro study on sheep tibias. Acta Orthop Traumatol Turc., 2025;59(6):421-427.
Prevalence and associated risk factors of neck pain in the Turkish population: A population-based study.
Aydın HZ, Güney C, Aydın K … +5 more , Yıldız NG, Karaboğa HA, Phiri YVA, Kahraman Güloğlu F, Aydın S
Acta Orthop Traumatol Turc · 2025 Nov · PMID 41578790 · Full text
OBJECTIVE: This study aimed to determine the prevalence of neck pain in the Turkish population and its association with sociodemo graphic factors, work status, self-rated health, obesity, depression, physical activity, n...
OBJECTIVE: This study aimed to determine the prevalence of neck pain in the Turkish population and its association with sociodemo graphic factors, work status, self-rated health, obesity, depression, physical activity, non-prescribed medications, and vitamin/nutritional supplements. METHODS: A cross-sectional study was conducted using data from the 2019 Türkiye Health Survey, which included 17 084 participants aged ≥15 years. Descriptive and multivariate binary logistic regression analyses were performed to investigate the prevalence of neck pain and its associated risk factors. RESULTS: Neck pain prevalence increased with age, peaking between 35 and 65 years old. Women were 3.2 times more likely to experience neck pain than men. Married and divorced individuals had higher risks than single individuals did. There was no significant relation ship between neck pain and educational level or physical activity. Self-rated health showed a strong inverse relationship with neck pain: "good" health increased risk 11 times, "fair" 64 times, "poor" 145 times, and "very bad" 387 times compared to "very good" health. House workers had a lower risk (0.8 times) compared to employees, while pre-obese and obese individuals had a 1.2 times higher risk. Neck pain was twice as common in those using non-prescribed drugs and 1.3 times more common in those using vitamins and supplements. CONCLUSION: Neck pain is prevalent in Türkiye, with factors such as age, sex, marital status, employment, health status, obesity, and use of non-prescribed drugs and supplements as significant risk factors. This study provides a reference for understanding neck pain, its associ ated factors, and guiding future research. Cite this article as: Aydın HZ, Karaboğa HA, Yıldız NG, et al. Prevalence and associated risk factors of neck pain in the turkishTurkish population: A population based study. Acta Orthop Traumatol Turc., 2025;59(6):463-469.
Application of patient-specific surgical guides in foot and ankle surgery.
Kavak S, Ozturk B, Ogut T … +3 more , DiGiovanni CW, Ashkani-Esfahani S, Karaismailoglu B
Acta Orthop Traumatol Turc · 2025 Dec · PMID 41578789 · Full text
Three-dimensional printing has rapidly evolved into an important technology in orthopedic surgery, enabling the creation of patient-spe cific instruments, implants, and anatomical models. As printing has become more affo...
Three-dimensional printing has rapidly evolved into an important technology in orthopedic surgery, enabling the creation of patient-spe cific instruments, implants, and anatomical models. As printing has become more affordable and accessible, point-of-care manufacturing has increasingly allowed clinicians to design and produce surgical aids directly within clinical units. This development, combined with advances in computed tomography (CT)-based imaging and segmentation software, has significantly expanded the use of patient-specific surgical guides (PSGs), particularly in foot and ankle surgery, where complex multiplanar deformities, poor soft-tissue, and limited visu alization often create technical challenges. Patient-specific surgical guides are generated from thin-slice CT data and allow surgeons to accurately transfer preoperative planning to the operative field. Their use has been reported across a wide range of procedures, including deformity correction, joint fusion, ankle arthroplasty, etc. Across these applications, studies consistently demonstrate improved osteot omy accuracy, enhanced deformity correction, reduced operative time, lower fluoroscopy exposure, and greater reproducibility between surgeons. The increasing adoption of weight-bearing CT has further strengthened the accuracy of preoperative planning by capturing true functional alignment. Despite these advantages, several limitations persist, including increased preoperative imaging requirements, higher initial costs, and dependency on manufacturing logistics. Most published studies remain level III-IV, with limited long-term data on clinical outcomes and cost-effectiveness. Nevertheless, as technological capabilities improve and workflows become more efficient, PSGs are poised to become an integral component of personalized foot and ankle surgery, with the potential to enhance both surgical precision and patient outcomes. Cite this article as: Kavak S, Ozturk B, Ogut T, DiGiovanni CW, Esfahani SA, Karaismailoglu B. Application of patient-specific surgical guides in foot and ankle surgery. Acta Orthop Traumatol Turc., 2025;59(6):340-348.
Total femoral replacement for oncologic indications: Functional outcomes, complications, and implant survival rates.
Kaya H, Vahabi A, Daştan AE … +3 more , Çolak TS, Keçeci B, Sabah D
Acta Orthop Traumatol Turc · 2025 Nov · PMID 41578788 · Full text
OBJECTIVE: Total femoral replacements for oncological indications are a rare indication, and there is limited data on functional outcomes, complications, and implant survival rates. The purpose of this study was to inves...
OBJECTIVE: Total femoral replacements for oncological indications are a rare indication, and there is limited data on functional outcomes, complications, and implant survival rates. The purpose of this study was to investigate functional outcomes, the rate and nature of com plications associated with this technique, and the survival rates of the implant used. METHODS: This is a retrospective case series from a single subspeciality orthopedic oncology unit in an urban referral center that evalu ated patients treated between January 2000 and May 2023. A total of 27 patients were included in the final analyses. The Musculoskeletal Tumor Society (MSTS) scoring system was used for functional evaluation. The received adjuvant-neoadjuvant chemotherapies and radio therapies, resected soft tissues during index surgery, complications, the number and extent of secondary surgical interventions, and data on local recurrence were recorded through chart review. Data on implant loss for any reason was also recorded. Complication-freesurvival rate and implant- loss-free survival rate were calculated using the Kaplan-Meier estimator at 60 months. The Henderson clas sification system was used to categorize failure modes. RESULTS: The median MSTS score at the most recent follow-up was 21 (range: 17-23). A total of 16 complications occurred in 13 patients. Only one of these complications was an intraoperative issue. Ten of the 16 complications necessitated one or more secondary surgical interventions. The most common complication was infection, occurring in 8 patients. Other complications included hip pain that neces sitated total hip arthroplasty, leg-length discrepancy, and spontaneous patella fractures, each occurring in 2 patients. At 60 months, 10 patients (37%) experienced complications. The mean estimated complication-free survival was 39 months (95% CI: 29-49). There were 6 patients in total who experienced implant loss. Infection was the sole cause of implant loss in 4 patients. Implant loss occurred in 1 patient due to recurrence and in another patient due to a combination of recurrence and infection, which led to amputation in both cases. The mean estimated implant-loss-free survival was 50 months (95% CI: 42-58). CONCLUSION: Total femoral replacement is reserved for distinctly specific oncological indications, where other more biological reconstruction methods are not feasible. This technique could yield satisfactory functional outcomes, along with a favorable implant survival rate and complication-free survival rate at mid-term. Infection remains the most common complication associated with this technique, while the main causes of implant failure are infection and local recurrence. Future studies focusing on strategies to prevent such complications and define clearer patient selection criteria may substantially improve the overall success of this technique. Cite this article as: Kaya H, Vahabi A, Daştan AE, Çolak TS, Keçeci B, Sabah D. Total femoral replacement for oncologic indications: Functional outcomes, complications, and implant survival rates. Acta Orthop Traumatol Turc., 2025;59(6):477-484.
Prospective comparative study of arthroscopic rotator cuff repair with or without acellular dermal matrix augmentation: Clinical and radiological outcomes.
Sastre S, Pérez ML, Postnikov Y … +6 more , Madariaga S, Arman A, Peidro L, Claret G, Pomenta V, García-Tarriño R
Acta Orthop Traumatol Turc · 2025 Nov · PMID 41578784 · Full text
OBJECTIVE: To prospectively evaluate the safety and effectiveness of arthroscopic acellular dermal matrix (ADM) augmentation of large rotator cuff tear repairs (RCR) in a comparative study. METHODS: A prospective single-...
OBJECTIVE: To prospectively evaluate the safety and effectiveness of arthroscopic acellular dermal matrix (ADM) augmentation of large rotator cuff tear repairs (RCR) in a comparative study. METHODS: A prospective single-center series of 20 patients undergoing arthroscopic RCR. The patients were randomized to arthroscopic transosseous-equivalent rotator cuff patch augmentation repair with a decellularized dermis prepared in the tissue bank or a control group without augmentation. Preoperative and postoperative functional outcomes were assessed by The University of California- LosAngeles (UCLA) score. Magnetic resonance imaging (MRI) evaluation was obtained 1 year after surgery. All adverse events were recorded. Statistical analysis was performed in R 4.2 (Boston, USA), using non-parametric group tests for paired data to evaluate functional results. The mean age was 59 years in the ADM group and 56.7 years in the control group. The gender distribution was 60% male and 40% female in both groups. RESULTS: Each group consisted of 10 patients, with no statistically significant differences observed in age, body mass index, or preoperative UCLA assessment. In the ADM augmentation group, 2 patients required reoperation due to re-tear before the end of the follow-up period.No statistically significant differences were found in functional outcome measures at any of the evaluation points. Final MRI identified 5 reruptures in the matrix group and 6 in the control group, showing no statistical difference between groups. No adverse events attribut able to the presence of the grafts were detected. CONCLUSION: These findings suggest that ADM augmentation may yield outcomes comparable to standard care, in terms of UCLA scores and re-tear rates. No adverse events related to ADM were observed. Cite this article as: Sastre S, Pérez ML, Postnikov Y, et al. Prospective comparative study of arthroscopic rotator cuff repair with or without acellular dermal matrix augmentation: Clinical and radiological outcomes. Acta Orthop Traumatol Turc., 2025;59(6):446-451.
Age-dependent associations between spinopelvic alignment and foot axes: A retrospective radiographic study.
Roch FE, Kletschka F, Jäckle K … +5 more , Meier MP, Stinus H, Lehmann W, Perthel R, Roch PJ
Acta Orthop Traumatol Turc · 2025 Dec · PMID 41578782 · Full text
OBJECTIVE: This study aimed to investigate the relationship between spinopelvic parameters and radiographic foot axes and to examine whether these associations differ across age groups. METHODS: This retrospective radiog...
OBJECTIVE: This study aimed to investigate the relationship between spinopelvic parameters and radiographic foot axes and to examine whether these associations differ across age groups. METHODS: This retrospective radiographic study analyzed imaging from patients treated at a university medical center for degenerative or traumatic conditions. Cases with weight-bearing, 2-view foot radiographs and standing lumbar spine radiographs, including the femoral heads, were included. Spinopelvic parameters (lumbar lordosis, pelvic tilt, sacral slope, and pelvic incidence) and radiographic foot axes (including hallux valgus angle, tibiotalar angle, and metatarsal declination angle) were measured, and correlation analyses were per formed with age-based subgroup comparisons. RESULTS: A total of 46 Caucasian patients (33 females, 13 males) were included (mean age 55.6 ± 18.5 years). Lumbar lordosis showed a significant negative correlation with hallux valgus angle (r = -0.29, P = .015). Sacral slope was negatively correlated with the hallux valgus angle (r = -0.42, P < .001). Pelvic tilt correlated positively with tibiotalar angle (r = 0.34, P = .004) and metatarsal declination angle (r = 0.25, P = .042). Age-stratified analyses demonstrated age-related differences in correlation patterns. CONCLUSION: Spinopelvic alignment demonstrates measurable associations with radiographic foot alignment, supporting the concept of the spine-pelvis-lower-limb unit as a biomechanically integrated system. Clinically, these findings suggest that integrated, chain oriented assessment and management strategies (considering both spinal and foot alignment, particularly with aging) may be relevant when evalu ating patients with coexisting spine and foot disorders. Cite this article as: Roch FE, Kletschka F, Jäckle K, et al. Age-dependent associations between spinopelvic alignment and foot axes: A retrospective radiographic study. Acta Orthop Traumatol Turc., 2025;59(6):379-386.
Improving subtalar arthrodesis with a skin-matched patient-specific surgical guide: A comparative cadaveric study.
Karaismailoglu B, Subasi O, Tung WS … +9 more , Ozturk B, Demirci E, Celayir A, Sevgil BS, Kargın F, Aydıngöz Ö, Aydın N, DiGiovanni CW, Ashkani-Esfahani S
Acta Orthop Traumatol Turc · 2025 Nov · PMID 41578776 · Full text
OBJECTIVE: To evaluate the accuracy and fluoroscopy shot count of a novel skin-matched, patient specific Instrument (PSI) for subtalar arthrodesis compared with the conventional freehand technique in a cadaveric setting....
OBJECTIVE: To evaluate the accuracy and fluoroscopy shot count of a novel skin-matched, patient specific Instrument (PSI) for subtalar arthrodesis compared with the conventional freehand technique in a cadaveric setting. METHODS: Twelve cadaveric specimens were randomized into PSI-guided (n = 6) and freehand (n = 6) groups, with preoperative computed tomography scans used to design 3D-printed guides. Each PSI incorporated 2 pre-angled cannulated sleeves to allow optimal guidewire placement from the calcaneus into the talus. Outcomes included fluoroscopy usage, number of wire placement attempts, angular devia tion between planned and actual wire trajectories (assessed in sagittal, coronal, and axial planes), and linear deviations at entry (calcaneal) and distal (talar) points. Statistical analysis used the Mann-Whitney U and Wilcoxon signed-rank tests with significance set at P < .05. RESULTS: Fluoroscopy usage was significantly lower in the PSI group (median 3.0 [interquartile range, IQR 3.0-6.0]) compared with the free hand group (17.0 [15.3-18.8]; P = .009). Similarly, the number of attempts was reduced in the PSI group (2.0 [2.0-2.8]) versus the freehand group (6.0 [5.3-6.8]; P = .009). Angular deviation from the preoperative plan was low (median 3.0° [IQR 1.8°-4.7°]), indicating high trajec tory fidelity. Linear deviation at the calcaneal entry point was minimal (median 0.9 mm [IQR 0.4-1.2 mm]), whereas greater variability occurred distally at the talar point (median 3.6 mm [IQR 2.0-5.1 mm]), remaining within clinically acceptable limits. CONCLUSION: The use of a skin-matched PSI for subtalar arthrodesis significantly reduced the number of fluoroscopy shots and wire place ment attempts while ensuring high accuracy of guidewire trajectory. These findings support the potential of 3D-printed PSIs to improve surgical precision, suggesting clinical applicability for subtalar arthrodesis and related hindfoot interventions. Cite this article as: Karaismailoglu B, Subasi O, Tung W, et al. Improving subtalar arthrodesis with a skin-matched patient-specific surgical guide: a comparative cadaveric study. Acta Orthop Traumatol Turc., 2025;59(6):368-373.
Retrospective clinicopathological analysis of 193 cases of bone and soft tissue tumors in the foot and ankle.
Yıldırım S, Çiftdemir M, Salih O … +3 more , Ustabaşıoğlu FE, Üstün F, Usta U
Acta Orthop Traumatol Turc · 2025 Dec · PMID 41578774 · Full text
OBJECTIVE: The aim of this study was to evaluate the epidemiological features, anatomical distribution, and treatment methods of bone and soft tissue tumors in the foot and ankle region. METHODS: This retrospective study...
OBJECTIVE: The aim of this study was to evaluate the epidemiological features, anatomical distribution, and treatment methods of bone and soft tissue tumors in the foot and ankle region. METHODS: This retrospective study included 193 cases evaluated at the musculoskeletal tumor board of the institution between January 2014 and December 2024. Patients' demographic data (84 males, 109 females; mean age, 37.8 years), lesion type, anatomical location, histopathological subtype, and treatment modalities were recorded. Tumors were classified according to the 2020 World Health Organization classification of bone and soft tissue tumors. RESULTS: Of the 193 cases, 128 (66.3%) were true tumors and 65 (33.7%) were tumor-like lesions. Among the tumors, 70 (54.7%) were bone tumors, 54 (42.2%) were soft tissue tumors, and 4 (3.1%) were metastases. Benign lesions accounted for 79.7%, malignant for 14.0%, and intermediate for 6.3% of all tumors. Tumors were most frequently located in the forefoot (44%), followed by the ankle (29%). Intraosseous lipoma was the most common benign bone tumor, giant cell tumor of the tendon sheath the most common benign soft tissue tumor, and ganglion cyst the most frequent tumor-like lesion. Excisional biopsy was the main treatment, whereas amputation was mainly performed for malignant tumors. CONCLUSION: Foot and ankle tumors are rare but clinically significant as misdiagnosis or delayed diagnosis can lead to poor outcomes. Although most are benign, malignant cases, especially in the ankle region, require aggressive management. Awareness of their regional distribution and histopathological spectrum is essential for early recognition, accurate diagnosis, and appropriate treatment planning. Cite this article as: Yıldırım S, Çiftdemir M, Salih O, Ustabaşıoğlu FE, Üstün F, Usta U. Retrospective clinicopathological analysis of 193 cases of bone and soft tissue tumors in the foot and ankle. Acta Orthop Traumatol Turc., 2025;59(6):485-492.
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