Total hip replacement for an ochronotic patient: A technical trick.

PATIENT: Male, 46 FINAL DIAGNOSIS: Akkaptonuria Symptoms: Hip pain Medication: - Clinical Procedure: Total hip replacement Specialty: Orthopedics and Traumatology. OBJECTIVE: Unusual or unexpected effect of treatment. BACKGROUND: Ochronosis is an inherited metabolic disease in which there is an accumulation of excessive amounts of homogentisic acid in the connective tissue. As the disease progresses, the chronic inflammation in the damaged tissue can cause degeneration and osteoarthritis. There is no specific treatment for ochronosis because it is a rare disease and arthroplasty is seldom performed. CASE REPORT: We report the case of a 46-year-old male patient with ochronosis, who underwent an arthroplasty of the right hip due to osteoarthritis. The problems encountered during surgery are reported and discussed. CONCLUSIONS: Arthroplasty is a highly effective procedure for ochronotic patients. Particular attention to the surgical step is highly advised.

Isolated sacral dislocation in a 4-year-old child.

Sacral dislocation is an uncommon form of injury in childhood. A 4-year-old girl who was injured in a motor vehicle accident was seen in the emergency room. On physical examination, ecchymosis and tenderness in the abdomen and sacral region was identified. Radiographs revealed no pelvic pathology. CT was performed owing to the patient's sacral and abdominal tenderness. Dislocations were identified at the sacral third and fourth vertebrae without any fractures. The patient was discharged 10 days later with a recommendation for 6 weeks bed rest and an appointment for an outpatient follow-up examination. At the post-traumatic second-month examination, the patient was walking normally. In the radiograph and MRI that were taken a year later, the dislocation was observed to have fused completely, and no pressure was seen on any anatomical structure. No functional pathology was identified during the interview with the family.

Traumatic shoulder fracture-dislocation in a 7-year-old child: a case report.

INTRODUCTION: In contrast to adults, traumatic glenohumeral dislocation is a rarely observed condition among children. In some cases, success in durable reduction with conservative methods, and achieving lasting treatment, may not be possible. CASE PRESENTATION: In this study, the case of a 7-year-old Turkish girl with a Salter-Harris type II fracture and glenohumeral dislocation of the proximal humerus due to a fall from a height of 1.5 meters who underwent open reduction surgery is presented along with a review of the literature. CONCLUSION: Orthopedic surgeons should consider glenohumeral dislocation which is an extremely rare condition when they encounter proximal humerus fractures in pediatric trauma.

Extra-articular Tenosynovial Chondromatosis Mimicking a Neoplastic Disease in the First Web Space of the Hand.

Tenosynovial chondromatosis is a very rare disease. The most common symptom is a slowly enlarging soft tissue mass, which may be painful or cause limitation of joint motion. Plain radiograph may appear normal during early phases of the disease, but subsequent imaging may be necessary to exclude other pathologies. Nonoperative treatment may be elected for some patients, but a synovectomy and the removal of loose bodies are indicated for persistent symptoms. This report describe a case with a multinodular cartilaginous proliferation and rice body in the first web space of the hand, similar to synovial chondromatosis, but arising in the tenosynovial membranes.

The effects of dexmedetomidine on ischemia reperfusion injury in patients undergoing arthroscopy under spinal anesthesia.

OBJECTIVE: Ischemia and reperfusion injury due to tourniquet application during arthroscopy is a well known problem. This study aimed to compare the effects of dexmedetomidine and ketamine on hemodynamic and respiratory variables and on total anti-oxidant status (TAS), total oxidant status (TOS) and malondialdehyde (MDA) as markers of ischemia-reperfusion injury. MATERIALS AND METHODS: This study was approved by a local ethics committee. The study was performed on patients undergoing arthroscopic operation under spinal anesthesia. Thirty patients were randomized into two groups: Group D (dexmedetomidine; n=15) and Group K (Ketamine; n=15). Spinal anesthesia at the L2-4 level was achieved using a 25G spinal needle with hyperbaric bupivacaine at a dose of 12-15 mg in all patients. In Group D, patients were sedated with dexmedetomidine at a dose of 0.3-0.5 µg/kg/h, while Group K received ketamine at a dose of 1-1.5 mg/kg/h. Hemodynamic parameters, oxygen saturation, Ramsey sedation scale (RSS), and TAS, TOS, and MDA levels were recorded. RESULTS: Demographic parameters, TAS, TOS and MDA levels were similar between groups. In Group K, the TOS levels after tourniquet removal were significantly lower than at baseline and during the use of the tourniquet. Preoperative hemodynamic and respiratory variables were similar in both groups. Blood pressure values were decreased compared to baseline but these decreases were not statistically significant. CONCLUSION: In patients undergoing arthroscopy under spinal anesthesia, dexmedetomidine had effects similar to ketamine, led to insignificant alterations in hemodynamic and respiratory variables during surgery and had comparable effects on ischemia-reperfusion injury. Thus, we think that dexmedetomidine can be a safe alternative to ketamine as an intraoperative sedative.

Complete lumbar spine duplication in a neurologically intact man.

BACKGROUND: Duplication of spine is a rare abnormality. Additional vertebral deformities and severe neurovascular, genitourinary, and gastrointestinal system abnormalities coexist in the majority of the cases. DESIGN: Case report. FINDINGS: A 44-year-old asymptomatic man was found to have double vertebral and double dural abnormalities of the lumbar spine as an incidental radiographic finding. Unlike most people with split cord malformations, this patient had no neurologic symptomatology or any other systemic abnormality. CONCLUSION: In our search of the literature, we did not find another case in a person of this age without any concomitant abnormalities.

Bilateral femur fracture in a newborn: an extreme complication of cesarean delivery.

INTRODUCTION: Bilateral femoral fracture due to birth trauma which is extremely rare, can occur during cesarean section. MATERIAL AND METHODS: This case represents a newborn delivered by cesarean section for breech presentation who sustained bilateral subtrochanteric fracture of the femur. RESULT: The newborn was treated with immobilization in pelvipedal cast. CONCLUSION: It has been concluded that performing accurate delivery technique and immediate evaluation-orthopedic consultation of the newborn in the presence of forced obstetrical maneuver are important.

Talonavicular joint approach to the talar body: a cadaver study.

BACKGROUND: Lesions of the talar dome or tumors within the talar body may require an open approach with medial or lateral malleolar osteotomies. The aim of this study was to evaluate the possibility and feasibility of a new minimally invasive approach without osteotomy, using the talonavicular joint (TJ) as the entry portal for lesions of the talar body. MATERIALS AND METHODS: Nine cadaveric feet were used for this study. Using the TJ and a 5-mm skin incision we aimed to reach the superolateral, superomedial, inferolateral and inferomedial corners of the talar body under fluoroscopy. A 2-mm Kirshner wire and a 4-mm cannulated drill bit were used to reach the desired target area and an angled curette was used for curettage after reaching the target. The proximity of vascular structures to the entry portal was noted. The talar and navicular joint surfaces were checked for any damage. The articular areas of the talar heads and the defect areas were measured. RESULTS: All 4 targets and even the posterior talus could be reached by this approach. The nearest neurovascular structures were the saphenous vein and the saphenous nerve. The navicular cartilage was not damaged in any specimen. The talar defect area corresponded to only 3.3% of the talar head cartilaginous area. CONCLUSION: The TJ approach can be used to reach lesions in all regions of the talar body without the need for an osteotomy. A mini-incision may be used to retract the saphenous nerve and vein. Damage to the talar head cartilage is minimal with this approach which requires no special equipments. CLINICAL RELEVANCE: This study shows that talar dome lesions can be reached with a minimally invasive method.

Mini-open versus all-arthroscopic rotator cuff repair: comparison of the operative costs and the clinical outcomes.

INTRODUCTION: Rotator cuff injury is one of the most frequently encountered problems of the shoulder in the daily practice of orthopaedic surgeons. This study compared all-arthroscopic cuff repair (ARCR) and mini-open rotator cuff repair (MORCR) methods in regard to clinical outcomes and costs. METHODS: Fifty patient charts and operative repairs were analysed (25 ARCR and 25 MORCR). Pre-and postoperative Constant-Murley and UCLA scores along with factors such as tear size, tear type, pre-operative physical therapy, motion and satisfaction levels were compared for the two procedures. Cost-benefit analysis was also performed for comparison between procedures. The duration of follow-up was 31.20 and 21.56 months for MORCR and ARCR groups, respectively. RESULTS: Tear sizes (P=0.68), pre-and postoperative Constant-Murley and UCLA scores (P=0.254) and satisfaction levels were not significantly different between groups. However, the differences between pre-and postoperative Constant-Murley and UCLA scores were statistically significant within both groups (P<0.01). The MORCR group stayed 1 day longer in hospital than the ARCR group, which was statistically significant (P=0.036). The differences regarding mean pain scores, abductions, internal and external rotations in Constant-Murley scores and forward flexion scores in UCLA scores were not significant. The ARCR group cost more, leaving less profit. CONCLUSION: Results suggest that ARCR yields similar clinical results but at a higher cost compared with MORCR.

Outcome in unilateral or bilateral DDH treated with one-stage combined procedure.

UNLABELLED: The surgical treatment of patients with neglected developmental dysplasia of the hip (DDH) has been the subject of controversy. We asked if age affected outcome in patients with neglected DDH with unilateral or bilateral dislocation who underwent one-stage combined procedures. We retrospectively reviewed the results of 40 patients (51 hips) treated with a one-stage combined procedure consisting of open reduction, pelvic osteotomy, and femoral shortening. The average age at the time of surgery was 5.4 years for Group I (bilateral dislocation, 22 hips) and 6.7 years for Group II (unilateral dislocation, 29 hips). Mean followup was 5.4 years for Group I and 6.7 years for Group II. According to the modified score system of Trevor et al, 13 hips rated excellent, three were good, and six were fair in Group I; the ratings were 14, nine, and six hips respectively in Group II. Four patients had a limb-length discrepancy of approximately 1.5 cm in Group I. Twelve hips in Group I and 18 hips in Group II had osteonecrosis of varying severity. Our data suggest the outcomes of the children who were 5.5 years or younger in Group I and 8 years or younger in Group II were better. LEVEL OF EVIDENCE: Level IV, case series. See the Guidelines for Authors for a complete description of levels of evidence.

Spontaneous giant expanding thigh hematoma mimicking soft tissue neoplasm.

We present a case of giant chronic expanding hematoma occurring in the left lateral thigh without any history of trauma or chronic medical disease. In our case, a diagnosis was unable to perform through conventional diagnosis method, which was confirmed by histopathological examination after successful surgical treatment. We suggest that patients who present with slowly growing extremity masses without trauma, in addition to soft tissue sarcoma and malignancy, chronic expanding hematoma should be considered in the differential diagnosis.

Clinical results versus subjective improvement with anterior transposition in cubital tunnel syndrome.

This study was conducted to compare the results of anterior transposition methods and to determine the time needed to attain subjective well-being in patients with cubital tunnel syndrome. A total of 49 cases were retrospectively evaluated. Patients were called for follow-up, completed a questionnaire, and were reexamined. They were assigned to one of 3 groups: subcutaneous transposition (SCT), submuscular transposition (SMT), or intramuscular transposition (IMT). The McGowan classification and Wilson-Krout criteria were used for classification and outcomes assessments. Categorical variables were analyzed with the chi2 test, and metric variables by analysis of variance or through Kruskal-Wallis variance analysis. Improvement of at least 1 McGowan grade was observed in 87.63% of patients. The least responsive group was assigned a McGowan grade of III. The most effective procedure for resolving clawing was SMT. Clinical results were excellent in 26 patients (53.06%), good in 12 (24.48%), fair in 4 (8.16%), and poor in 7 (14.28%). At the latest follow-up, overall grip and pinch strength had improved by 23% and 34%, respectively, compared with the contralateral side. Thirty-six patients exhibited an improvement in grip power and 38 in fine dexterity. Complete resolution of numbness was observed in 32 patients, and complete resolution of pain was noted in 30 patients. The preoperative mean visual analog scale score of 6.82 improved to 3.36 postoperatively. Clawing improved in 4 patients and atrophy in 7. The mean time to subjective improvement was shortest in the SMT group and longest in the IMT group. The greatest pain relief was reported in the IMT group and the least in the SMT group. One case with IMT required reoperation because of recompression of the nerve. The most frequent complication in the SMT and IMT groups was muscular tenderness. In conclusion, SCT offers an alternative to other anterior transposition methods because of its simplicity and quicker recovery time, especially in mild to moderate cases.

Effect of strontium ranelate on fracture healing in rat tibia.

OBJECTIVES: Various anti-osteoporotic agents are available for clinical use. In contrast to other anti-osteoporotic drugs, strontium ranelate has anti-resorptive and bone-forming effects (dual action). Our objective in the present study is to investigate the efficacy of strontium ranelate (SR) on fracture healing in rat tibia. METHODS: Forty-two male Wistar rats randomized into two groups (groups 1 and 2, n=21 for each). Left tibiae of all animals were broken in a closed manner using a manual three-point bending technique through mid-tibia following deep anesthesia with ketamine. The animals in group 1 were fed 25g/day specially produced food containing 450mg/kg SR starting from the first post-operative day. Group 2 were given 25g/day normal food. The animals were sacrificed on the 2nd, 3rd and 4th post-operative weeks (each week 7 animals were sacrificed from each group) and the broken tibiae were removed. The tibiae were examined first radiographically and second, histopathologically. RESULTS: Radiologically, callus maturity and bone union increased with time in both groups. But no significant differences were found regarding callus maturity and bone union in weekly comparisons (p=0.52, p=0.19, p=0.74). CONCLUSIONS: Histopathologically, it was seen that the fractures remarkably healed steadily in both groups on the 2nd, 3rd and 4th post-operative weeks. But no significant differences were found regarding the progression of fracture callus in weekly comparison (p=1.0, p=0.52, p=1.0). In the present study, we were unable to find any beneficial or harmful effects of strontium ranelate on fracture healing.

Intraosseous ganglion of the talus treated with the talonavicular joint approach without exposing the ankle joint.

Intraosseous ganglion, which is generally seen in metaphyseal-epiphyseal regions of long bones, is not a rare disorder. It is extremely rare in the talus, however. Differential diagnosis of a cystic talar lesion should include enchondroma, chondroblastoma, giant cell tumor, and unicameral bone cyst. This article presents a case of intraosseous ganglion of the talus in a 38-year-old woman treated with a new surgical approach and technique. The patient had mild ankle pain at the arc of motion in her right ankle that increased with activity. Radiographs and magnetic resonance images showed a cystic lesion in the medial side of the talar dome. It was treated by curettage and autocorticocancellous bone grafting through an opening in the talonavicular joint without disturbing the intact talar dome cartilage. One month after the operation, the patient had an excellent clinical outcome. This approach and technique can be used to treat other lesions of the talus that do not involve the joint space.

The healing potential in cauda equina syndrome secondary to traumatic posterior L5-S1 dislocation. A case report with 16 years follow-up.

Cauda equina syndrome is the result of any lesion that compresses or paralyzes cauda equina roots which are both motor and sensory. It is an uncommon syndrome, which features low back pain, sciatica, variable lower extremity motor and sensory loss with possible bladder and bowel dysfunction. It is an emergency situation as it may cause significant morbidity such as permanent paralysis, impaired bladder and/or bowel control or loss of sexual sensation. We present the case of a patient who was admitted to the emergency department with a traumatic posterior L5-S1 dislocation, low back pain and bladder dysfunction 8 days following an initial trauma. Open L5-S1 reduction and posterior stabilization was performed and the dural sac was decompressed. Most of the patient's neurological deficits resolved over several years, following the initial surgery.