Can Anatomical Differences Contribute to the Etiology of Danis-Weber Type B Lateral Malleolus Fractures?

Introduction Lateral malleolus fractures are among the most common ankle fractures, but the anatomical factors that may predispose individuals to this specific type of fracture are not fully understood. This study aims to explore whether distinct anatomical characteristics of the ankle joint contribute to an increased susceptibility to lateral malleolar fractures. Methods A retrospective analysis was conducted on 73 patients diagnosed with isolated lateral malleolar fractures between 2020 and 2023. An array of radiologic parameters, including distal tibial articular surface (DTAS) angle, bimalleolar tilt (BMT), medial malleolar length (MML), lateral malleolar length (LML), medial malleolar relative length (MMRL), lateral malleolar relative length (LMRL), medial malleolar slip angle (MMSA), talocrural angle (TCA), anterior inclination of the tibia (AI), and fibular position (FP), were meticulously measured on anteroposterior and lateral ankle radiographs for each study participant. We also measured the same parameters in 126 individuals who had not experienced an ankle fracture for comparison. Results Statistically significant differences were observed between the fracture group and the control group for DTAS angle, BMT, MML, MMRL, LMRL, TCA, AI, and FP (p<.05). Conversely, LML and MMSA displayed no significant variations between the two groups (p=0.745 and p=0.623). Effect sizes were notably large for DTAS and TCA, medium for MMRL, BMT, and AI, and small for LMRL, MML, and FP. Conclusion Our findings indicate an increased risk of lateral malleolus fractures in individuals with a relatively longer medial malleolus, a valgus-oriented ankle, reduced anterior inclination of the tibia, and an anteriorly positioned fibula. Taking protective measures during risky activities in individuals with these differences may help to prevent fractures.

Twelve to Twenty-year Follow-up of Dega Acetabuloplasty in Patients With Developmental Dysplasia of the Hip: Is it as Effective as Expected?

BACKGROUND: Although Dega acetabuloplasty is widely used for the treatment of developmental dysplasia of the hip, there is a paucity of data on long-term outcomes. The purpose of the study was to evaluate the rate of residual acetabular dysplasia after Dega acetabuloplasty. METHODS: Patients of a previously reported consecutive series of 35 patients (43 hips) operated by a single surgeon were recontacted for long-term follow-up. Of these, 25 patients (32 hips) consented, with a follow-up rate of 71% (74% of hips). The mean age at the time of surgery was 35 (18 to 65) months. The presence of residual dysplasia was noted according to the lateral center-edge angle of Wiberg, femoral head extrusion index, and Tönnis angle. The latest radiographic outcome was evaluated according to the Severin classification and patients were clinically evaluated according to the modified McKay criteria. RESULTS: The mean follow-up duration of 16.5 (12 to 20) years yielded an average age of 19.2 (14 to 23) years at the time of analysis. According to lateral center-edge angle, femoral head extrusion index, and Tönnis angle, 5 (15.6%) hips were dysplastic and 2 (6.3%) hips were reoperated for resubluxation. Thus, a total of 7 hips (21.9%) were considered to have residual dysplasia. With the exception of 2 hips that underwent further osteotomies, no other hips were re-subluxated or redislocated. Overcoverage was noted in 6 (18.7%) hips. There were 26 Severin group I and II (81.3%), 4 Severin group III (12.5%), and 2 Severin group IV (6.2%) hips. According to modified McKay criteria, 20 (62.5%) hips were excellent, 7 (21.9%) hips were good, and 5 (15.6%) were fair. Severin classification and modified McKay criteria were correlated with dysplasia ( P < 0.05). CONCLUSIONS: Seventy-eight percent of the hips treated by Dega acetabuloplasty for developmental dysplasia of the hip did not have acetabular dysplasia at a mean follow-up of 16 years. Even in well-treated asymptomatic hips, patients should be followed regularly, especially for residual dysplasia. LEVEL OF EVIDENCE: Level IV.

Complex rigid foot deformity correction with hexapod external fixator system.

PURPOSE: Complex rigid foot deformities include three-plane deformities and usually presents with poor soft tissue coverage. In the last decades, gradual correction with computer-assisted fixator became an appropriate option for the treatment rigid foot deformities. This study aims to report our experience about treatment of complex foot deformities using Smart Correction fixator system®. METHODS: We retrospectively analyzed 13 complex rigid foot deformities of ten consecutive patients treated with Smart Correction fixator system® from 2016 to 2020. Primary outcomes were classified as good, fair, and poor according to previously determined criteria. The outcomes were also assessed with The Manchester-Oxford Foot Questionnaire (MOXFQ). Non-parametric analysis (Wilcoxon test) for continuous variables and the Fisher's exact test for categorical variables were used. RESULTS: Plantigrade foot was achieved in all patients after correction program. Supramalleolar osteotomy was applied in nine feet, midfoot osteotomy was applied in two feet, hindfoot osteotomy was required in one foot, and only soft tissue distraction performed in two feet. Two patients had recurrent deformity managed by further acute corrections. The mean MOXFQ scores improved from 72.7 preoperatively to 24.8 at last follow-up. CONCLUSIONS: Present study shows that SCF the reliable option for the treatment of complex foot deformities, which also facilitates three-plane correction and concomitant lengthening with gradual soft tissue balance.

Intraoperative medial wall disruption in Dega pelvic osteotomy: Does it effect the radiographic outcome at medium-term?

OBJECTIVES: To compare the radiographic outcomes of our patients who encountered medial wall disruption, with those who did not while undergoing Dega osteotomy. METHODS: We retrospectively reviewed the records of 95 hips with developmental dysplasia of the hip who were treated with Dega pelvic osteotomy. Hips were divided into 2 groups according to medial wall disruption: group A included the hips with medial wall disruption, while group B included the hips without disruption. Preoperative, immediate postoperative, 12 weeks and last follow-up anteroposterior radiographs of the pelvis were reviewed for changes in the acetabular index (AI) between groups. RESULTS: There were 22 hips in group A and 73 hips in the group B. Preoperative (34.6 versus [vs] 37.2, p=0.231), postoperative (17.9 vs 18.4, p=0.682), 12th week (18 vs 18, p=0.504) and last follow-up (13.3 vs 15.1, p=0.097). The acetabular index measurements were comparable between the groups. Corrections achieved during surgery, and during the follow-up period were also comparable between the two groups, indicating no loss of radiographic correction caused by medial wall disruption. Ninety one percent of the patients in group A and 90% of group B achieved good or excellent results according to the Severin classification (p=0.944). CONCLUSION: Our study shows that disruption of the medial wall did not have a significant detrimental effect on radiographic correction when performing Dega osteotomy.

Fixation techniques in lower extremity correction osteotomies and fractures in mild-to-severe osteogenesis imperfecta patients: evaluation of the results and complications.

INTRODUCTION: Osteogenesis imperfecta is a genetic disorder leading to multiple fractures and deformities. Intramedullary rods have been used in the surgical treatment of osteogenesis imperfecta for decades. Complication rates reported by current techniques have been high. This study aimed to examine the results of intramedullary fixation combined with plate and screw technique in patients with osteogenesis imperfecta compared to isolated intramedullary fixation. METHODS: Between 2006 and 2020, forty patients who had surgical treatment for deformities or fractures of the femur, tibia or both with at least two years of follow-up after surgery were included in the study. Patients were divided into groups according to fixation methods. Group 1 was intramedullary fixation only (Titanium Elastic Nail [TEN], Rush Pin, and Fassier-Duval Rod), and Group 2 was intramedullary fixation combined with plate and screws. Medical records and follow-up radiographs were reviewed to evaluate healing and callus formation, types of complications and infection rates. RESULTS: The total number of operated lower extremities of these forty patients was 61 (45 femur and 16 tibia). The mean age of the patients was 9.3 ± 4.6 years. Mean follow-up duration of the patients was 4.4 ± 1.7 years. Thirty-seven (61%) were in Group 1, and 24 (39%) were in Group 2. There was no statistically significant difference in callus formation time between Group 1 and Group 2 (p = 0.67). Complications occurred in 21 of 61 surgeries. While 17 of these complications were in Group 1, 4 were in Group 2 (p = 0.01). CONCLUSION: Intramedullary fixation combined with the plate and screw technique in children with osteogenesis imperfecta is successful considering the complications and revision requirements.

Accuracy of the hexapod external fixator in treating tibial angular deformities with or without limb length discrepancy: a retrospective study.

OBJECTIVE: Hexapod external fixator systems allow simultaneous deformity correction in multiple planes as well as limb lengthening. The aim of this study is to evaluate the accuracy of a hexapod frame (smart correction frame) in different types of tibial deformities requiring correction with or without lengthening. METHODS: A total of 54 tibial angular deformities and limb length discrepancies operated with a hexapod frame between January 2015 and January 2021 were classified into four groups: "Group A ( n  = 13): only lengthening," "Group B ( n  = 14): lengthening and uniplanar correction," "Group C ( n  = 16): only uniplanar correction," and "Group D ( n  = 11): biplanar correction." The accuracy of angular deformity correction/lengthening was calculated by dividing the actual correction/lengthening achieved after frame removal by the preoperative planned lengthening/correction. RESULTS: The lengthening accuracy in Group A and Group B was 96.3 ±â€…7.1% and 95.7 ±â€…5.9%, respectively ( P  = 0.685). The angular deformity correction accuracy was 85.1 ±â€…9.9% for Group B, 85.2 ±â€…13.9% for Group C, and 80.2 ±â€…18.4% for Group D ( P  = 0.852). A revision program was performed in six cases (1 in Group B, 1 in Group C, and 4 in Group D) for full correction of the deformities. CONCLUSION: The accuracy of tibial lengthening is high with the hexapod frame and is minimally affected by simultaneous deformity correction; however, the accuracy of angular correction slightly reduces as the deformity becomes more complex. Surgeons should be aware that reprogramming may be required after complex deformity correction.

Examination of Upper Extremity Length Discrepancy in Patients with Obstetric Brachial Plexus Paralysis.

Since the natural course of obstetric brachial plexus palsy is variable, several problems are encountered. One important question, in considering patients with OBPP under observation in outpatient clinical settings, is whether children will have length discrepancies in their arms. The aim of this study was to determine differences in the length of the affected extremity, in comparison to the opposite upper extremity. As such, 45 patients, aged 6 months to 18 years, with unilateral brachial plexus palsy developed due to obstetric reasons, were included in the study. Affected and healthy side humerus, ulna, radius, 2nd metacarpal and 5th metacarpal lengths were evaluated according to gender, age, side, Narakas classification, primary and secondary surgery. Statistically significant differences were found in the change rates of affected/healthy humerus, radius, 2nd metacarpal and 5th metacarpal lengths according to age (93%, 95%, 92%, 90% and 90%, respectively). Affected/healthy change rates of ulna, radius, 2nd metacarpal and 5th metacarpal lengths were found to differ statistically (p < 0.05) according to the Narakas classification variable (94%, 92%, 95%, 94% and 94%, respectively). There were no statistically significant differences in the ratios of affected/healthy change in the lengths of the humerus, ulna, radius and 5th metacarpal compared to the primary surgery (p > 0.05). The ratios of affected/healthy change in ulna, radius and 5th metacarpal lengths were found to differ statistically (p < 0.05) according to secondary surgeries (93%, 91%, 91% and 92%, respectively). Joint and bone deformities and bone shortening were observed after changes that occurred in the postnatal and growing periods due to obstetric brachial plexus palsy. Every increase in function to be gained in the upper extremity musculature was also potentially able to reduce problems, such as shortness.

Femoral lengthening using limb reconstruction system augmented with only one antegrade flexible nail in children: early results.

Several techniques have been described for decreasing the duration of external fixator use, augmenting stability, and minimizing complications. The purpose of the present study was to evaluate the clinical results and complications of femoral lengthening procedures using the Limb Reconstruction System (LRS) in combination with a single antegrade flexible intramedullary nail (FIN). Femoral lengthening with LRS and FIN was applied to 14 patients (aged 6-16 years) between 2017 and 2021. The etiology was a congenital femoral deficiency in 12 patients and post-traumatic growth arrest in two. A single nail was inserted antegradely through the trochanteric apophysis in each patient. Radiographs and medical records of the patients were assessed retrospectively. The mean lengthening achieved was 4.8 ±â€…1.0 cm. The mean duration of external fixation was 181 days (range 139-248 days) and the mean healing index was 39.6 ±â€…12.1 days/cm. The mean values of mechanical medial proximal tibial angle, mechanical lateral distal tibial angle, mechanical lateral proximal femoral angle, and mechanical lateral distal femoral angle were within the normal range at the last follow-up. Seven of the 14 cases had a regenerate deformity that caused a displacement of more than 2 mm in the mechanical axis deviation, none of them was greater than 10 mm and considered clinically insignificant. Fracture was seen in two limbs with regenerate deformity. This study suggests that LRS in combination with only one FIN may be an effective alternative for femoral lengthening, with acceptable complication rates.

The clinical results of lower trapezius tendon transfer with the peroneus longus allograft augmentation combined with interpositional repair with fascia lata in massive irreparable rotator cuff tears.

OBJECTIVES: To investigate the clinical results of lower trapezius (LT) tendon transfer and interpositional repair that were performed simultaneously in patients with massive irreparable rotator cuff tears. METHODS: Between 2018 and 2020 years, 16 patients with massive irreparable rotator cuff tears that were treated with LT tendon transfer and interpositional repair at the same time were included in this study. The mean follow-up period was 29±3 months (24-39 months) and the mean age of patients was 62±9 years (42-73 years). The acromio-humeral distance, active range of motions, Visual Analog Scale (VAS) scores, University of California-Los Angeles (UCLA) scores and Constant-Murley scores were made preoperatively and at the final follow-up. RESULTS: At the final follow-up, forward flexion was increased from 109˚±24.7 to 144˚±22.21 (p=0.005), abduction from 60˚±16.33 to 135˚±16.33 (p=0.005) and external rotation from 12˚±16.87 to 35˚±14.34 (p=0.005). Total UCLA scores were 5.9±2.13 to 22.7±5.29 (p=0.005), Constant-Murley scores were 24±9.43 to 50.2±14.28 (p=0.008), VAS scores were 6.1±1.1 to 2.4±1.35 (p=0.007), mean acromio-humeral distances were 4.64±0.85 mm (3.42-6.23 mm) to 6.58 mm (5.25-8.21 mm) (p=0.005) preoperatively and at the final follow-up. Except one patient who had a frozen shoulder any significant complication was detected. CONCLUSION: Adding interpositional repair to the LT tendon transfer in patients with posterior superior irreparable rotator cuff tear seems to have satisfactory short to mid-term clinical outcomes without an increase in complications.

Low dose vancomycin-loaded spacers for two-stage revision knee arthroplasty: High success, low toxicity.

BACKGROUND: Two-stage revision arthroplasty is a widely used treatment method for infected knee arthroplasty. Loading high doses of antibiotics to spacer during the first stage is standard practice. However, there are reported systemic side effects attributed to antibiotic-loaded spacers. The aim of our study is to investigate the success rate and systemic toxicity following the first stage revision knee arthroplasty with low-dose vancomycin-loaded spacers. METHOD: We included patients with infected knee arthroplasty eligible for two-stage revision arthroplasty from 2001 to 2020. One gram of vancomycin is added per pack of bone cement. Spacers were handmade in the operating theatre. Following the first stage, pre-operative and postoperative culture results, infection parameters, kidney and liver function tests, and functional scores were analyzed. Kaplan-Meier survival analysis was done to determine the success rate. RESULTS: Fifty patients with a mean follow-up of 48 months (24-108) were included in the study. A five-year survival analysis showed an 88.5% success rate. Fourteen percent of the patients had acute kidney injury with creatinine levels between 1.12-2.80 mg/dl, and 8% had a mild drug-induced liver injury with elevated serum ALT levels between 223-540 U/L and total bilirubin levels between 0.59-1.23 mg/dl. None of the patients required dialysis. All of the systemic side effects were reversible. CONCLUSION: Our results have suggested that low dose antibiotic-loaded spacers are comparable to the studies with high dose antibiotic loaded spacers regarding infection eradication and survival rates. They are less likely to cause severe systemic side effects. Therefore we suggest low dose antibiotic-loaded spacers should be considered when treating patients with vancomycin sensitive Staphylococcal species and culture negative infected knee arthroplasty.

Closed versus medial open reduction in the treatment of developmental dysplasia of the hip under age 1: A retrospective comparative study.

OBJECTIVE: This study aimed to compare the mid-term results of closed reduction (CR) versus medial open reduction (MOR) in the treatment of children with developmental dysplasia of the hip (DDH) under age 1. METHODS: Thirty-four patients with DDH (41 hips) were included in this retrospective study with a mean follow-up of 4.2 years (range: 2-6.9 years). All hips were then divided into 2 groups based on the treatment type: the CR group (20 hips) and the MOR group (21 hips). All hips from both groups were assessed with post-spica magnetic resonance imaging (MRI) in the first 24 hours, and reinterventions were recorded. Medial dye pool width was also measured. RESULTS: Age at the time of reduction was similar between the CR and MOR groups (6.6 ± 1.3 months vs. 6.7 ± 1.6 months). There was no significant difference between groups regarding avascular necrosis rate and further corrective surgery (FCS) requirement (P=.454, .697). The appropriate reduction was seen at 38/41 hips. Three hips in the CR group had revealed dislocation in post-spica MRIs and required re-intervention, and none of the hips in the MOR group required re-intervention (P=.107). Medial dye pool width in 3 planes showed no significant difference between MOR and CR. CONCLUSION: There is no difference in the avascular necrosis rate and FCS requirements between CR and MOR under age 1. Post-spica MRI is a favorable tool for evaluating reduction after CR, but its efficacy after MOR is questionable.

An Alternative Fixation Option for Subtrochanteric Femur Fractures in Children: Adult Proximal Humerus Plate.

BACKGROUND: Subtrochanteric femur fractures are unstable injuries due to strong muscle forces on the proximal femur. The ideal fixation device is controversial in the treatment of subtrochanteric femur fractures in children. The aim of this study is to evaluate the clinical and radiological outcomes of subtrochanteric femur fractures in children treated with an adult proximal humerus plate. METHODS: A total of 9 patients [mean age at surgery, 8.3 years (range: 7 to 12); mean follow-up period, 28.1 months (range: 12 to 56)] who underwent surgery due to a subtrochanteric femur fracture and treated with an adult proximal humerus between January 2017 and December 2021 were retrospectively evaluated. Four of the patients had a pathological fracture associated with a benign bone tumor while 5 patients had a nonpathological fracture. The clinical and radiological outcomes were assessed using the Flynn scoring system at the latest follow-up. Time to union and complications were recorded. RESULTS: All patients demonstrated a solid fusion of the fracture site and were able to bear full weight at the latest follow-up. The mean time to union was 8.2 weeks (range: 6 to 10). Based on the Flynn scoring system at the latest follow-up, seven patients had excellent clinical outcomes and two patients had satisfactory outcomes. Two patients had limb length discrepancy, and one patient had coxa valga and a limb length discrepancy of 16 mm. There were no patients with nonunion, infection, implant failure, osteonecrosis of the femoral head, and heterotopic bone formation. CONCLUSION: This study suggests that the adult proximal humerus plate may be an effective alternative fixation option in the treatment of subtrochanteric femur fractures in children, including pathological fractures. LEVEL OF EVIDENCE: Level IV, Case series.

Evaluation of different intraarticular injection volumes to assess optimum efficient amount; an experimental study in rat knee joints.

INTRODUCTION: The injection amount of solutions differs in wide ranges, from 20 to 200 µL in intraarticular injections experiments that was carried out with rats. The 10-fold difference between applied volumes is not acceptable since injection errors might affect the outcomes of the studies significantly. The excessive amount of solution that was injected into the knee joint of rats might end up with leakage of the solution from injection aperture, and damage the articular structures etc. In our preliminary experiments, we mentioned problems during the injection of excessive amount of solution into the rat knee joint. The main purpose of the present study, which was performed with rat knee joints, was to evaluate the applicability of different amounts of solutions used in experiments and to determine the optimal volume for intraarticular injection in rats. METHODS: The volume of 100 µL water-based stain was administered into knee joints of non-living rats. The legs were dissected to evaluate the possible presence of injected solution outside the knee joint. Then, the decreasing volumes (100 µL, 50 µL, 40 µL and 30 µL) of X-ray contrast solution (lobitridol) were applied into the knees of living rats to investigate whether systemic circulation acts on the leakage outside the joint. The X-ray images of all these joints were also taken to confirm the results. RESULTS: In nonliving rats, the place where water-based strain overflow from the knee joint was pointed out. The place of leakage is where the tendo musculi extensor digitorum longus leaves outside the joint. In living rats, by using contrast solution, an overflow was noticed in the subdermal place with the intraarticular injection volumes of 100 µL, 50 µL, and 40 µL. No overflow was observed with the intraarticular injection volumes of 30 µL X-ray contrast solution. DISCUSSION: In conclusion, the injection volume for the knee joints of rats should not exceed the 30 µL for optimum efficiency.

Minimally Invasive Surgical Approach Using an Equal-Sized Plate as an External Guide to Lateral Malleolar Fractures.

BACKGROUND: For minimally invasive percutaneous plate osteosynthesis (MIPPO) techniques applied to fractures of the lateral malleolus, there is no external guide for inserting the plate, determining the incision, and inserting the screws as used for fractures in other regions. With MIPPO, fluoroscopy exposure is unavoidable. The MIPPO technique is advantageous for patients; however, the unavoidable problem with this method for the surgical team is repeated exposure to fluoroscopy. To expose the surgical team to least radiation, we used a novel technique with an equal-sized plate as an external guide. We present the results of patients treated with this technique. METHODS: Patients with isolated lateral malleolar fracture who underwent MIPPO using an equal-sized anatomical lateral malleolar plate as an external guide were retrospectively investigated. VAS scores on postoperative day 1 and AOFAS scores at final evaluation were noted. RESULTS: Twenty-six patients were included in the study. Mean ± SD follow-up was 42.46 ± 14.11 months. Mean ± SD VAS score on postoperative day 1 was 3.76 ± 2.58. On final evaluation, prominent implant was identified in two patients, with mean ± SD AOFAS score of 98.00 ± 2.17. No other complications were observed. CONCLUSIONS: Using an equal-sized plate as external guide may ensure less use of fluoroscopy while determining the incisions. Until an external guide is produced commercially for minimally invasive fixation of lateral malleolar fractures, this method ensures determination of incisions and insertion of screws without requiring the use of fluoroscopy and may be reliably used for minimally invasive surgery.

Reconstruction of periacetabular tumours with saddle prosthesis or custom-made prosthesis, functional results and complications.

Reconstruction after resection of pelvic tumours is a major challenge. We report the outcomes and complications of 7 patients who underwent limb salvage following type II or type II, III pelvic resection and reconstruction using a saddle prosthesis or custom-made hemipelvic prosthesis. In our opinion, reconstruction using custom-made prostheses is better than placement of saddle prostheses because of a lower risk of complications and improved functional outcomes.

Intralesional curettage and cementation for low-grade chondrosarcoma of long bones: retrospective study and literature review.

BACKGROUND: Various treatment strategies for low-grade chondrosarcomas with variable outcomes have been reported in the literature. The aim of this study was to assess the oncological and functional outcomes associated with intralesional curettage followed by adjuvant therapy comprising high-speed burring, thermal cauterization, and bone cementation with polymethylmethacrylate. METHODS: We performed a retrospective review of 21 consecutive patients with intramedullary low-grade chondrosarcoma of long bones treated by intralesional curettage and adjuvant therapy comprising high-speed burring, thermal cauterization, and cementation at our institution from 2007 to 2012. RESULTS: The average age of the patients was 48.7 (range, 18-71) years. There were 7 male and 14 female patients. The mean follow-up period was 58.4 (range, 26-85) months after surgery. The treated lesions were located in the proximal humerus (n=10), proximal tibia (n=6), and distal femur (n=5). At the average follow-up time point of 58.4 (range, 26-85) months, no patient had developed local recurrence and no distant metastases were observed. The average Musculoskeletal Tumor Society score among all 21 patients was 95% (84-100). CONCLUSIONS: The combination of intralesional curettage, application of high-speed burring, thermal cauterization, and cementation is an effective treatment strategy for low-grade intramedullary chondrosarcoma of long bones. Excellent oncological and functional results can be obtained.

Neonatal physeal separation of distal humerus during cesarean section.

Diagnosing physeal separation of the distal humerus in a newborn can be challenging. Skeletal immaturity and absence of secondary ossification centers make radiographic diagnosis difficult for inexperienced providers. This fracture is seen in the setting of complicated deliveries with excessive traction and rotation applied to the forearm. We report a case of physeal separation of the distal humerus in a newborn as a complication of cesarean section and describe the intervention used and the short-term results.