Determining bone bruises of the knee with magnetic resonance imaging.

INTRODUCTION: Injuries that develop secondary to minor traumas and cannot be detected via direct examination methods, but are detected via advanced imaging methods, such as magnetic resonance (MR) imaging, are called occult bone injuries or bone bruises. In such injuries, diagnostic arthroscopy usually does not reveal any pathology. MR imaging methods are quite beneficial for the diagnosis of such clinical conditions, which cause acute pain and restriction of motion. The present study aimed to assess occult bone injuries via MR imaging in patients who presented with minor knee trauma. PATIENTS AND METHODS: Twelve patients who presented with minor knee trauma were included in the study. Etiological factors in these patients included walking a long distance, falls, and minor trauma. All patients underwent physical examinations, direct radiological imaging, MR imaging, and diagnostic arthroscopy. RESULTS: Direct radiographs of the patients showed no pathological fracture. Bone marrow changes detected on the MR images were classified according to Lynch's classification as Type I lesions in nine patients and Type II lesions in three patients. CONCLUSION: We suggest that MR imaging methods should be the gold standard for the diagnosis of minor traumatic bruise injuries of the knee.

Open ankle dislocations without associated fracture.

BACKGROUND: This study aimed to clarify the intermediate followup results of reduction without soft tissue repair in open ankle dislocations without fracture. METHODS: We retrospectively reviewed cases of open isolated ankle dislocations without associated fracture. Five male patients treated between January 2005 and July 2009 were enrolled in this study. Debridement and reduction with primary wound closure of the skin were performed without suture of the capsule or repair of the ligaments. The outcome was evaluated by the American Orthopaedic Foot & Ankle Society score (AOFAS). The time period for returning to previous level of activity was also recorded. RESULTS: The average age of the patients was 34 (range, 27 to 44) years, and the average followup was 4 (range, 2 to 6) years. The average of the last control AOFAS score was 90 (range, 84 to 98) points. Two ankles were rated as excellent, and the other three were rated as good. Patients returned to their previous levels of physical activity at an average of 9 weeks. CONCLUSION: Favorable long-term results were obtained for reduction without ligament repair in pure ankle dislocations.

Are sinus-track cultures reliable for identifying the causative agent in chronic osteomyelitis?

PURPOSE: The infection of bone that contains bone marrow called osteomyelitis, and is caused by different microorganisms. In this study, we aimed to determine the diagnostic value and accuracy of cultures of material from a sinus track compared with those of cultures of bone specimens that have been controversial. MATERIALS AND METHOD: Prospective study was conducted at Hospital University of Dicle, a 1,090-bed university-based hospital located in Diyarbakir, Turkey. Between May 2005 and September 2006, sinus-track cultures were compared with those of bone cultures from 43 patients with chronic osteomyelitis. RESULTS: The patients' mean age was 30.6 +/- 3.6 years, and 29 (67%) male and 14 (33%) female. Organisms isolated from bone cultures were Staphylococcus 69% (29/42), Escherichia coli 9.5% (4/42), Pseudomonas aeruginosa 9.5% (4/42), Proteus mirabilis 7% (3/42), respectively. Cultures of sinus track and bone specimens gave identical results in 38% of patients. CONCLUSION: The value of bone culture in the therapy of osteomyelitis must be emphasized; it is the only reliable means of determining the responsible agent, up on which the antibiotic therapy is based. The correlation between sinus track and bone cultures was 38%, i.e., failure in the treatment for 6 patients out of 10.

Post therapeutic lower extremity rotational profiles in children with DDH.

PURPOSE: The purpose of this study was to investigate post-therapeutic lower extremity rotational profiles in children with developmental dislocation of the hip (DDH), the differences between these values and those of normal children, and the relationship between these differences and clinical and radiological results. METHODS: In 82 lower extremities of 64 patients, the foot-progression angle was measured clinically and the transmalleolar axis angle photographically, and hip rotations and thigh-foot angle were measured both clinically and photographically. The data obtained were compared with Staheli's data for normal children. In addition, clinical and radiographic data were compared within subgroups and with Staheli's data. Student's t-test and one-way ANOVA were used for statistical evaluation. RESULTS: The medial rotation of the hip, the average clinical value was 44.66 masculine, and the photographic value was 42.28 masculine. Lateral rotation of the hip, the average clinical value was 38.01 masculine, and the average photographic value was 37.29 masculine. Thigh-foot angle, his angle was clinically 8.23 masculine and photographically 9.68 masculine. Angle of the transmalleolar axis, the photographic average was 21.59 masculine. Foot-progression angle, the clinical average was 10.70 masculine. It was determined that the lower extremity rotational profiles of children with DDH treated after walking did not differ from those of normal children, but that the internal and external hip rotations of McKay type III and IV patients were below those of normal children and of McKay type I and II patients. CONCLUSION: Lower extremity rotational profiles in children with DDH who received appropriate treatment were the same as those for normal children.

Is varus osteotomy necessary in one-stage treatment of developmental dislocation of the hip in older children?

PURPOSE: Innominate osteotomy, varisation-derotation osteotomy, and shortening osteotomy are the most common surgical procedures used to achieve pelvifemoral realignment in the treatment of children over three years of age with developmental hip dislocation. It is well known that varus osteotomy can improve the acetabular index but it does have some disadvantages. The aim of this study was to discuss the results obtained with patients treated only with Salter osteotomy, derotation osteotomy, and shortening, without varus osteotomy, and to evaluate the need for varisation on the basis of these results. METHODS: Between 1996 and 2001, twenty-four hips, sixteen unilateral and four bilateral, of a total of twenty patients treated with this method and available for final controls were evaluated. The study included sixteen female and four male patients with a mean age of 4 years 2 months (ranging between 2 years 10 months and 8 years). The mean follow-up period was determined as 6.57 years (range 5-10 years). McKay's clinical criteria, Sever's radiological criteria, and the evaluation system modified by Trevor et al. were used for evaluation of the results. RESULTS: Based on McKay's clinical criteria, eighteen hips (75%) were classified as type I, four hips (16%) as type II, and two hips (9%) as type III. According to Sever's radiological criteria, thirteen hips (54%) were graded as grade I, nine hips (37.5%) as grade II, and two (8.5%) as grade III. According to the modified evaluation system of Trevor et al. the results were categorized as excellent in thirteen hips, good in nine hips, and moderate in two hips. Pre-operative mean acetabular index was measured as 37.3 degrees (28 degrees -50 degrees ) and early post-operative mean acetabular index as 26 degrees (18 degrees -38 degrees ). In the final radiological examination the mean acetabular index was measured as 18.3 degrees and the mean CE angle as 30.1 degrees (15 degrees -38 degrees ). Avascular necrosis affecting the results developed in five hips. CONCLUSION: It is concluded that in older children with developmental dislocation of the hip (DDH) treated with one-stage combined surgical intervention, adequately stable concentric reduction can be achieved without varisation and that varus osteotomy is not always necessary.

The role of melatonin as a link between head injury and enhanced osteogenesis.

We hypothesize that in the case of an individual with a head injury, melatonin can enhance osteogenesis. In virtually all species to date whether nocturnal or diurnal, melatonin is synthesized and secreted during the dark phase of the day. In traumatic subarachnoid hemorrhages, in the hypothalamic syndrome, the melatonin content was very high in liquor. This was determined by a fluorimetric method, especially modified for this purpose. Osteoblastic activity rises with the increase of melatonin. Healing of a fracture of long or large bone can often be accelerated in patients with severe traumatic brain injury. However, a melatonin which could perhaps induce enhanced osteogenesis has not yet been identified. Melatonin might cause early bone healing and hypertrophic callus.

Use of the vastus lateralis muscle flap with a grooving procedure in the surgical treatment of chronic osteomyelitis of the femur.

Severe femoral fractures may be associated with devascularization of cortical bone, soft-tissue loss, and significant morbidity. After surgical treatment of these femoral fractures, chronic infection may ensue and requires additional reconstructive procedures. Local muscle flap coverage is used to treat chronic osteomyelitis. A new procedure-the vastus lateralis muscle flap with grooving of the femoral shaft-was used for the treatment of chronic osteomyelitis of the femoral shaft. The authors present 6 patients with chronic osteomyelitis of the femur who were treated with a vastus lateralis muscle flap. Five of the patients were male and the other was female. The average age of the patients was 33.8 years (range, 17-54 years). All patients experienced infection during the early postoperative period. Drainage of abscess, debridement, sequestrectomy repair of fistula, and mini fenestration were performed at least 3 times, and antibiotics were administered several times. During the operations, tissue samples were evaluated for bacterial cultivation. Staphylococcus aureus was seen in 4 patients, S. epidermidis in 1 patient, and Pseudomonas aeruginosa in the remaining patient. A vastus lateralis muscle flap with grooving of the infected femoral shaft is presented. The authors have not encountered a recurrence of infection during a minimum 3.9 years of follow-up. They think this technique is an alternative to the current techniques for the surgical treatment of chronic osteomyelitis of the femur.

Early prophylactic autogenous bone grafting in type III open tibial fractures.

The authors report the results achieved in patients with type III open tibial fractures who underwent primary autogenous bone grafting at the time of debridement and skeletal stabilisation. Twenty patients with a mean age of 35.8 years (range, 24-55) were treated between 1996 and 1999. Eight fractures were type IIIA, 11 were type IIIB, and 1 was type IIIC. At the index procedure, wound debridement, external fixation and autogenous bone grafting with bone coverage were achieved. The mean follow-up period was 46 months (range, 34-55). The mean time to fixator removal was 21 weeks (range, 14-35), and the mean time to union was 28 weeks (range, 19-45). Skin coverage was achieved by a myocutaneous flap in 2 patients, late primary closure in 4, and split skin grafting in 14. One (5%) of the patients experienced delayed union, and 1 (5%) developed infection. In tibial type III open fractures, skin coverage may be delayed, using the surrounding soft tissue to cover any exposed bone after thorough débridement and wound cleansing. Primary prophylactic bone grafting performed at the same time reduces the rate of delayed union, shortens the time to union, and does not increase the infection rate.

The results of rehabilitation on motor and functional improvement of the spinal tuberculosis.

OBJECTIVES: To evaluate the result of rehabilitation on motor and functional improvement in spinal tuberculosis. METHOD: Prospective case study. Data were collected from 47 patients with spinal tuberculosis medically and/or surgically treated, and rehabilitated over 6 months of period, after spinal decompression and fusion. The main outcome measures were motor development of the patients who were evaluated at the beginning, in the 1st week, in the 3rd month, and in the 6th month. Functional development of the patients was evaluated at the beginning and in the 6th month. Functional assessment was made according to Modified Barthel Index (MBI), and motor examination was made according to American Spinal Injury Association (ASIA). RESULTS: The study population consisted of 47 patients (22 males and 25 females) mean aged 37.9 +/- 18.3 years (range 5-76 years). The most common site of spinal tuberculosis was the thoracic region. Localized back pain, paraparesis, sensory dysfunction and fever were typical clinical manifestations. Surgical management was performed as anterior or posterior drainage of abscess and/or stabilization of the spine. The rehabilitation program was performed in all patients during the preoperative, early postoperative and late postoperative 6 month periods. Muscle-strengthening exercises on necessary localization such as pectoral, abdominal, lower extremities; truncal and sacrospinal extensors were started for the rehabilitation. The motor score for the lower limbs and the MBI scores for activities of daily living (ADL) and mobility improved significantly (P < 0.001). The self-care and mobility categories of the MBI on admission; were 14.8% severely dependent and 10.6% independent. However, at the end of the rehabilitation program, 4.2% were severely dependent and 70.2% independent. IN CONCLUSION: Early diagnosis and appropriate medical and/or surgical treatment together with a rehabilitation program will improve the life quality of patients with spinal tuberculosis.

Long-term outcomes of conservatively treated paediatric pelvic fractures.

The long-term orthopaedic, urologic, and psychiatric outcomes of patients treated non-operatively for unstable pelvic fractures were assessed. There were 55 males and 3 females with an average age of 7 (3-13). Eighty-one percent of the fractures were caused by motor vehicle accidents, and 68% by auto-pedestrian accidents. Thirty-four of the 58 fractures were type Tile type B and 24 were type C. Posterior urethral injury was determined in 41 patients, and head injury in 21. Three patients with type C injury died within the first 3 days. After an average follow-up period of 7.4 years of the patients with type B injuries, leg length discrepancy of 1cm was determined in two, and limited motion associated with open-knee wound in one, and low back pain in two. Of the patients with type C injuries, low back pain was found in four, gait abnormality in three, sacroiliac ankylosis in one, and symphyseal ossification in two. Urethral stricture was determined in 11 patients, urinary incontinence in 6 and erectile dysfunction in 6. A total of 31 patients were diagnosed with 41 psychiatric illnesses, including dysthymic disorder, social phobia, post-traumatic stress disorder, and major depression. No difference was found in the treatment outcomes of the two groups. From a holistic standpoint, long hospital stays and urologic complications are associated with serious psychological problems, and thus should be considered during selection of treatment modality.

Is external fixation in pediatric femoral fractures a risk factor for refracture?

The aim of this study was to investigate whether external fixation is a risk factor for refracture by comparing the outcomes of children who received three different forms of treatment of femoral fractures. One hundred ninety-two patients treated for femoral fracture between 1990 and 1999 who underwent final examination were assessed. One hundred were treated with hip spica casting after traction, 57 with closed reduction and external fixation, and 35 with open reduction and external fixation. Morbidity results such as time to union, length of hospital stay, refracture, and wire site infection were statistically evaluated. Patients undergoing open reduction had a greater time to union and length of hospital stay and a higher refracture rate. The difference was statistically significant. Wire site infection occurred in all three groups; there was no statistically significant difference between groups. The authors concluded that external fixation is not a risk factor for refracture in the treatment of pediatric closed femoral diaphyseal fractures, and that it may be used with ease in clinics with shortages of personnel and space.

Treatment of refracture occurring after external fixation in paediatric femoral fractures.

With a mean follow-up of four years, we assessed the outcomes of 11 refractures which occurred following paediatric femoral fractures treated by external fixation; the refractures were treated conservatively with simple immobilisation in a spica cast. A total number of 104 children with a femoral fracture were treated with external fixation between 1993 and 2000 in our institution. Refracture occurred in 11 cases after fixator removal. These patients were immediately placed in a hip spica cast. All 11 patients were boys, with a mean age of 7.3 years (range: 6 to 9), and the mean follow-up time was 4 years (range: 2 to 7). Mean hospitalisation time after refracture was 2 days (range: 0 to 4). Refractures occurred an average of 8 days (range: 1 to 21) after fixation removal. The mean time to union after refracture was 55 days (range: 35 to 62). On final evaluation, a mean limb length discrepancy of 0.9 cm (range: 0 to 2.5) was noted. Radiological study showed a mean lateral angulation of 5.6 degrees (range : 0 to 17) and a mean anterior angulation of 7.4 degrees (range: 0 to 20). Based on these findings, we believe that closed reduction and spica cast immobilisation is sufficient in cases with refracture of the femur after external fixation, but the option of surgical treatment should be considered when satisfactory anatomic reduction is not achieved.

The effects of electromagnetic field on distraction osteogenesis.

The effects of electromagnetic field on distraction osteogenesis and new bony tissue were investigated. Twenty-five New Zealand rabbits were divided into an experimental (12 rabbits) and a control (13 rabbits) group. An osteotomy was performed on the right tibia in the diaphyseal region in both groups. The experimental group was exposed to a magnetic field of 50 Hz 1.0 mT for 3 hours a day for 13 weeks. The control group was kept in a similar environment but with no electromagnetic field. The distraction was continued until an increase of 10 mm was achieved. At weeks 4, 8, and 13, radiography, scintigraphy, and a biopsy were performed in both groups, and the results were statistically analyzed. The X-ray results were similar in both groups at all times. On the other hand while the scintigraphic and histopathological results were similar at weeks 4 and 13 in both groups, the osteoblastic activity was significantly greater in the experimental group at week 8 (p < 0.01). In conclusion an electromagnetic field increases the osteoblastic activity and osteogenesis, but has little effect during the remodeling phase.

Anthropometric study of patients treated for clubfoot.

The anthropometric characteristics of patients treated for clubfoot were used to investigate whether the dimensions of the foot were affected by the method of treatment. A total of 68 patients followed up for an average of 9 years were divided into three groups: group 1, conservatively treated; group 2, surgically treated; group 3, conservatively treated on one side and surgically treated on the other. The following average discrepancies in foot length were obtained: group 1, 0.91 cm; group 2, 1.5 cm; group 3, 1.09 cm. Toe lengths were shorter to the same extent as the other dimensions of the foot. These discrepancies were statistically significant. The following average discrepancies in foot width were obtained: group 1, 0.05 cm; group 2, 0.37 cm; group 3, 0.054 cm; these were insignificant. The authors believe that the degree of discrepancy may depend not solely on the method, but on the severity of the deformity as well.

[The floating knee in adults: twenty-four cases of ipsilateral fractures of the femur and the tibia]. / Yirmi dört olguda ipsilateral femur ve tibia kirigi: Eriskinlerde "floating knee"

OBJECTIVES: We evaluated the presenting features of ipsilateral femoral and tibial fractures in adults, and the effects of both fracture type and severity of skeletal injury on the results. METHODS: The study included 24 patients (22 men, 2 women; mean age 38 years; range 17 to 75 years). According to the classification by Letts et al., the types of the fractures were as follows: type A (7), type B (2), type C (5), type D (7), and type E (3). Femur fractures were treated by locked intramedullary nails, AO plates, plate-screws, unilateral external fixator, or dynamic condylar screws, and tibia fractures by external fixator, plate-screws, locked intramedullary nailing, or with conservative methods. Amputation at the fracture level was required in a patient with type 3C open tibia fracture. The mean follow-up was 3.2 years (range 1.3 to 7 years). RESULTS: According to the criteria by Kalström and Olerud, the results were excellent in three patients, good in nine patients, fair in five patients, and poor in six patients. The mean skeletal injury scores were 4.4 and 3 in patients having fair and poor results and in those with good and excellent results, respectively. Fair and poor results corresponded to type A (1 patient), type C, type D, or type E fractures. Five patients with type 3 open fractures had fair or poor results. Thirteen patients (54%) had at least one complication. CONCLUSION: Patients with type C, D, or E fractures and those with greater skeletal injury scores are more likely to have fair or poor results due to the open nature of the fracture and to increased involvement of the knee joint. Although there is not an ideal method, rigid internal fixation seems to be more appropriate in fractures other than type 3 open tibia fractures.

[Comparison between the results of intramedullary nailing and compression plate fixation in the treatment of humerus fractures]. / Humerus kirikli olgularda kilitli intramedüller çivi ve plak ile tedavi sonuçlarinin karsilastirilmasi.

OBJECTIVES: The results of open reduction and internal fixation of humeral shaft fractures by either an intramedullary nail or a dynamic compression plate were compared. METHODS: The study included 60 patients (43 males, 17 females; mean age 38 years; range 19 to 61 years) with humerus fractures. Thirty-three patients were treated with intramedullary nails and 27 patients with dynamic compression plates. Functional results were evaluated according to the Stewart and Hundley's criteria. The two methods were compared. The mean follow-up period was 42 months (range 28 to 72 months). RESULTS: Healing times did not differ between the two treatment groups (p>0.05). Radial nerve palsy occurred only in the dynamic compression plate group, with four patients being affected. On the other hand, the rate of non-union was significantly higher in patients treated with intramedullary nailing (p<0.05). CONCLUSION: No ideal fixation technique exists in the treatment of humerus fractures. Despite higher non-union rates, intramedullary nailing may be the method of choice in the treatment of humerus fractures because of such advantages as low morbidity, small dissection of soft tissues, and greater ease of application.

Frontal cephalometric analysis in the evaluation of facial asymmetry in torticollis, and outcomes of bipolar release in patients over 6 years of age.

BACKGROUND: The aim of this study was to investigate the mid-term results of bipolar release in congenital muscular torticollis patients over 6 years of age, and the efficacy of frontal cephalometric analysis in the determination and follow-up of facial asymmetry. METHODS: Twelve patients (9 boys, 3 girls) from 7 to 12 years of age were included in the study. Bipolar release was performed, followed by 5-7 days of traction and 3 months of physiotherapy. Posteroanterior cephalometric radiography was performed at the beginning of and after therapy. The postural symmetry angle (PSA) was used to determine the presence and severity of facial asymmetry. A modified version of Lee et al.'s system was used in evaluating the results. RESULTS: The average follow-up period was 3 years and 5 months. According to the congenital muscular torticollis evaluation system, the outcome was excellent in 2 of the patients, good in 6, fair in 2 and poor in 2. Asymmetry was not severe in all patients at the beginning of therapy according to PSA values, being insignificant in 2, mild in 6, and severe in 4. The PSA results of the last examination indicated that severe facial asymmetry persisted in 3 patients. In 2 of them, PSA values remained within the limits of severe asymmetry despite a slight angular correction. DISCUSSION: Congenital muscular torticollis patients can benefit from surgical treatment over the age of 6 years. Bipolar release is an adequate and complication-free method. Moreover, PSA may be used as an objective method in the determination and follow-up of facial asymmetry in torticollis patients.

Problem fractures associated with gunshot wounds in children.

Twenty-seven fractures in 22 children (14 female, 8 male; average age: 10.5) who suffered gunshot wounds were retrospectively evaluated. Fourteen of the fractures were caused by high-velocity weapons, four by low-velocity weapons, and nine by shotguns. One of the fractures was undisplaced, two were displaced, 10 were comminuted, seven were comminuted and displaced, and seven had bony defects. Accompanying pathologies included four physeal, three articular, four visceral, four arterial, six peripheral nerve, and one spinal cord injury. Initial treatment involved external fixation in 15 patients and internal fixation in one patient for bone stabilization, while the remaining patients were treated conservatively.Late-stage surgery was necessary to achieve soft-tissue coverage in three patients and to achieve union in six patients. Major complications included amputation in one patient, non-union in two, delayed union in one, osteomyelitis in one, paraplegia in one, and loss of peripheral nerve functions in three. The treatment of fractures associated with firearm injuries in children is never simple. Fracture defects, accompanying peripheral nerve damage and involvement of the joint negatively is affect the outcome, increasing the chance that late-stage surgery will be necessary. Internal bone transport appears to be an efficacious technique in the treatment of bone and soft-tissue defects associated with firearm injuries in children.

[The treatment outcomes of children with Gustilo-Anderson grade II and grade III open fractures of the long bone]. / Cocuk uzun kemiklerinde Gustilo-Anderson Tip-2 ve Tip-3 açik kiriklarin tedavi sonuçlari.

BACKGROUND: We evaluated the treatment results in thirty-two children who had grade 2 and 3 open fractures according to classification of Gustilo-Anderson. METHODS: There were 21 (%65) male and 11 female (%35) patient and the mean age was 9 years (range, 4-14 years). There were 18 (%56) grade-2, 7 (%22) grade-3A, 5 (%15) grade-3B, and 2 (%6) grade-3C open fracture. All fractures were irrigated and debrided, and then fixed with external fixators. The average duration of follow-up was 11 months (range, 6-28 month). RESULTS: All fractures healed. Inadequate recovering was detected in four patients who had nerve injury, in addition the joint limiting contracture occurred on six patients. CONCLUSION: Fracture union without segmental bone loss is not a significant problem in open fractures in children, and that joint contractures, compartment syndrome and nerve injuries negatively affect the late outcomes.