Radiographical and clinical results of a new conservative treatment algorithm in Legg-Calvè-Perthes disease: A retrospective study.

OBJECTIVE: This study aimed to establish a feasible conservative treatment algorithm for Legg-Calvè-Perthes Disease (LCPD), clarify its limitations, and evaluate the correlations between radiographical and clinical results. METHODS: Patients diagnosed with LCPD and treated conservatively were evaluated retrospectively; 39 hips from 35 patients were included. The treatment protocol consisted of intermittent manual traction, range of motion exercises, activity limitation, bed rest, NSAID (ibuprofen 100mg/5mL), and ASA (100mg/day) during attack periods. The treatment protocol was standardized, and an algorithm was established for all the patients. RESULTS: The mean follow-up was 13.7 (range = 8-22) years. According to the Stulberg classification, 26 (67%) hips were good, 6 (15,3%) were fair, and 7 (17%) were poor. No activity-limiting pain was detected in any patient. The mean Harris score was 90.5 ± 5.3 for Stulberg type 1, 2, and 3 hips, but 84.2 ± 8.8 for Stulberg type 4 and 5 hips. When the patients were evaluated in terms of pain, activity, and func- tion, it was seen that pain and activity were not different, especially in the Stulberg 1, 2, 3, and 4 patients during the mid-term follow-up. The function was the main factor correlating with the Stulberg classification. Twenty-nine (82.8%) families defined the applicability of the treatment protocol as "easy," 4 (10.3%) defined it as "moderate," and 2 (6.2%) defined it as "difficult." CONCLUSION: The present study demonstrated that the treatment protocol was successful and easily applicable to LCPD. Although lateral pillar classification was efficient to predict radiographic results, the Stulberg classification was not correlated with the clinical results for every subgroup. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Effects of ZnO Nanoparticles and Ethylenediamine-N,N'-Disuccinic Acid on Seed Germination of Four Different Plants.

The release of nanoparticles and biodegradable chelating agents into the environment may cause toxicological and ecotoxicological effects. The aim of this study is to determine the ecotoxic effects of zinc oxide (ZnO) nanoparticles and ethylenediamine disuccinic acid (EDDS) on most cultured four plants. The durum wheat, bread wheat, barley, and rye are exposed to 5 mL 10 mg L-1 ZnO nanoparticles and 10 mg L-1 EDDS in the seed germination stage. Results show that these different plant species have different responses to ZnO nanoparticles and EDDS. The germination percentage of bread wheat and rye decreases in the application of ZnO nanoparticles while the germination of durum wheat and barley increases as much as in radicle elongation and seedling vigor. While ZnO treatment causes a decrease in bread wheat and rye germinated rat in the range of 33-14.3%, respectively, there is no change in germination rate of these plants at EDDS treatment. In addition, EDDS treatment positively affects barley germination rate. In conclusion, it is clear that ZnO nanoparticles have more toxic effects on bread wheat and rye than EDDS, while barley is positively affected by ZnO nanoparticles and EDDS.

Factors predicting the outcomes of incomplete triple pelvic osteotomy.

INTRODUCTION: In the present study, we identified factors affecting the outcomes of patients who underwent incomplete triple pelvic osteotomies due to acetabular dysplasia. METHODS: Data on a total of 58 hips in 50 patients for whom adequate data were available and who had undergone appropriate follow-up were retrospectively evaluated. We used Ömeroglu scores for radiological evaluation, Harris Hip Scores for clinical evaluation, Tönnis scores to evaluate osteoarthritis progression and a modified Clavien-Dindo classification to evaluate complications. RESULTS: The average patient age was 23.26 (14-47) years, and the average follow-up duration 105.59 (18-191) months. The complication rate was 10.3%, and complications negatively influenced clinical outcomes. Patients with radiologically poorer outcomes had more advanced osteoarthritis. We found minimal improvements in lateral centre edge angle (LCEA), refined centre-edge angle (RCEA), and lateral acetabulum head index (LAHI) were associated with osteoarthritis progression and that good improvements in LCEA, RCEA, acetabular angle (AA), and LAHI were associated with radiological outcomes. Neither patient age at the time of operation nor development of a postoperative relative crossover sign affected osteoarthritis progression or clinical or radiological outcomes. CONCLUSIONS: The most important factors influencing clinical outcomes were complications. However, neither postoperative acetabular retroversion nor a positive supra-equatorial crossover sign (often viewed as prognostically negative) directly affected clinical outcomes.When treating patients with acetabular dysplasia, either inadequate correction or overcorrection may negatively affect outcomes. In such patients, an incomplete triple pelvic osteotomy (allowing controlled correction) is both safe and effective.

Mid-term radiological and clinical results of incomplete triple pelvic osteotomy.

OBJECTIVE: The aim of this study was to assess clinical and radiological results of incomplete triple pelvic osteotomy in acetabular dysplasia. PATIENTS AND METHODS: Twenty-six hips of 24 patients (5 males, 19 females) treated with incomplete triple pelvic osteotomy by a single surgeon from February 1995 to October 2001 were retrospectively reviewed at an average follow-up time of 12 years. The mean age at the time of surgery was 21.6 years (range: 14-41). Radiological evaluation was based on the central edge angle, acetabular angle, acetabular index, acetabular head index and lateralisation. Clinical and radiological scoring was performed using the Harris scoring system, Ömeroglu scoring system and the Tönnis criteria for osteoarthritis. RESULTS: There was significant improvements in all of the radiological parameters with 88.5% good radiological results, 96.2% excellent clinical results, no significant progression to osteoarthritis and no need for conversion to total hip arthroplasty. The rate of major complication was 11%. Retroversion was seen in 15.4% of the hips. CONCLUSION: Our results support the use of incomplete triple pelvic osteotomy as a safe choice in the treatment of acetabular dysplasia as it offers clinical and radiological benefits and contributes to the prevention of osteoarthritis. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Middle and long term radiologic and functional results of childhood supracondylar humeral fractures operated in first 24 hours with limited medial approach.

OBJECTIVE: To investigate the middle- and long-term radiological and functional results of children with type III supracondylar humerus fractures treated with a limited medial approach and internal fixation. METHODS: The retrospective study was conducted at Department of Orthopaedics in Goztepe Training and Research Hospital, Istanbul, Turkey, and comprised data of children who underwent surgery between April 1991 and June 2009. Patients in group I underwent surgery within the first 8 hours after admission, and those in group II did so 8-24 hours after admission. Patients were evaluated according to the Flynn scoring system. RESULTS: Of the 79 patients, 52(65.8%) were male and 27(34.2%) were female. Fractures involved the left side in 49(62%) patients. Group I had 39(49.4%) patients and group II 40(50.6%). The overall mean age was 6.2±2.95 years (range: 2-13 years), and the mean follow-up was 53.2±14.9 months (range: 26-193 months). Functional scores were satisfactory (excellent, good and fair results) in all cases in both groups (100%), and the cosmetic results were satisfactory in 37(95%) in group I, and 39(97.5%) in group II (p>0.05). CONCLUSIONS: Limited medial approach to the treatment of supracondylar humerus fractures yielded successful functional and cosmetic results.

Developmental dysplasia of the hip associated with aplasia of the pubic bone (hook-pelvis): report of a case and review of the literature.

Aplasia of the pubic bone associated with congenital hip dislocation is rare. Various dysmorphic conditions featuring absence or hypoplasia of the ischiopubic bone, associated with congenital hip dislocation, have been distinguished in the literature. We report the case of an 18-month-old boy with developmental dysplasia of the hip associated with isolated total aplasia of the pubic bone. Patient was successfully treated with modified Salter osteotomy and reverse U-shaped capsuloplasty.

Transverse incision for calcaneal tuberosity avulsion fractures.

A number of incision options are available to surgeons approaching the posterior aspect of the calcaneus for repair of fractures of the posterosuperior aspect of the body of the calcaneus. In this brief communication, we depict our preference for the use of a transverse posterior calcaneal incision for reduction and fixation of avulsion fractures of the calcaneus. The advantages of this particular incisional approach include adequate exposure to the underlying target structures, orientation of the scar in line with relaxed skin tension lines, which minimizes scar formation, and avoidance of dissection of the Achilles tendon.

Closed total talar extrusion after ankle sprain.

Closed total talus dislocation from tibiotalar, subtalar, and talonavicular joints is a very rare injury. A 25-year-old young man, who had severe ankle distortion while walking down a flight of stairs, was brought to the emergency room complaining of a deformity and pain in his ankle joint. Roentgenographies revealed total talar body extrusion. The patient was treated urgently with open reduction in the authors' clinic. Tibialis posterior tendon might prevent closed reduction so open reduction with retraction of the tendon may be necessary.

Treatment of reverse oblique trochanteric femoral fractures with proximal femoral nail.

Treatment of reverse oblique trochanteric femoral fractures is still challenging. We present the results of our proximal nailing surgery performed for reverse obliquity intertrochanteric fractures using two lag screws and evaluated the quality of the reduction, operative time, complications and functional status of the patients. Fifteen patients with AO/OTA 31 A-A3 fractures were treated by proximal femoral nailing in our trauma centre. The mean Harris hip score was 74.66 (range 65-96) and the mean Barthel activity score was 15.71 (range 12-20). The mean duration of surgery was 48 minutes and the average consolidation time was 8.6 weeks. No intraoperative complications or postoperative technical failures and no stress shielding as evidenced by the lack of cortical hypertrophy at the level of the tip of the implant were detected. Intramedullary nailing with proximal femoral nails may be a good option in the treatment of reverse obliquity intertrochanteric fractures.

Early results of distal metatarsal osteotomy with K-wire fixation in the treatment of tailor's bunion.

OBJECTIVE: Tailor's bunion deformity is a lateral side bone and soft tissue prominence of the fifth metatarsal bone. The aim of our study was to assess the clinical and radiographic results of distal metatarsal osteotomies in patients with tailor's bunion deformity. METHODS: This study included 24 feet of 14 patients with tailor's bunion who were treated with distal metatarsal osteotomy of the 5th metatarsal between 2006 and 2009. The mean follow-up time was 24.45 (range: 12 to 47) months. Patients were evaluated clinically and radiographically, using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system with weight-bearing anteroposterior and lateral foot radiographs. RESULTS: Average AOFAS scores of the patients were 64.83 preoperatively and 91.62 at the final follow-up. Three patients had complications; avascular necrosis, delayed union, and superficial wound infection. CONCLUSION: Distal metatarsal osteotomy is a safe and easy treatment option for the painful tailor's bunion deformity and provides patient satisfaction rate of up to 96%.

Botulinum toxin as a solution in voluntary hip dislocation after modular unipolar hemiarthroplasty.

This article presents a case of an 82-year-old woman with Alzheimer's disease who was treated with a modular unipolar hemiarthroplasty for a right femoral neck fracture, which she voluntarily dislocated 3 times in the first postoperative week. The hip was stable in all directions, even in 60 degrees internal rotation, 0 degrees abduction, and 90 degrees flexion. The patient was mobilized 1 day postoperatively with full weight bearing. She dislocated her hip on postoperative day 3 while lying on her bed. After the dislocation, reduction under sedation was done again followed by a botulinum toxin injection of 50 IU to her adductor muscle group (including adductor longus, brevis, and magnus). The patient was mobilized after the injection and she had no difficulty walking. During the 6 months after the injection, no dislocation occurred again. Botulinum toxin decreases muscle activity by blocking the release of acetylcholine at the neuromuscular junction, thereby rendering the muscle unable to contract for up to 3 to 4 months. This method of botulinum injection can be applied to noncompliant patients with mental problems as an alternative conservative and surgical approaches.

Treatment of Tönnis type II hip dysplasia with or without open reduction in children older than 18 months: a preliminary report.

PURPOSE: In this study, we aim to investigate whether the hip with Tönnis type II dysplasia in children older than 18 months can be treated without open reduction. METHODS: In our study, 47 hips (47 patients) with type II developmental dysplasia of the hip according to the Tönnis classification were treated by a combination of open reduction through an anterolateral approach with iliopsoas tenotomy followed by innominate osteotomy and capsulorrhaphy or iliopsoas tenotomy followed by innominate osteotomy. The patients with open reduction constitute the open Salter group (32 hips), while the rest of the patients with innominate osteotomy alone constitute the closed Salter group (15 hips). The acetabular index (AI) and Smith's c-b and h-b index were assessed on the preoperative, immediate postoperative and final follow-up hip X-rays. RESULTS: There were no statistically significant differences related to sex distribution, age and postoperative follow-up time between the patients of each group. There was also no statistically significant difference between the preoperative AI of the open and closed Salter osteotomy groups. Overall, 80% of hips with open reduction had Smith's c-b ratio greater than the value of 1 and h-b ratio lower than the value of 0.05. CONCLUSION: The preoperative c-b index of the open osteotomy group was statistically greater than the c-b index of the closed osteotomy group and the preoperative h-b index of the open Salter group was statistically smaller than the h-b index of the closed Salter group, which means that most of the hips in the open osteotomy group are more in a lateralised and superior position compared to the closed osteotomy group. To us, there exists a subgroup of hips with less lateralisation and superior displacement according to the Smith's c-b and h-b ratio in Tönnis type II hip dysplasia. These hips might be less amenable to capsulorrhaphy because of the lower capsular instability and treatment may be done with closed reduction after iliopsoas tenotomy with Salter osteotomy in this select group of patients.

Torus fracture of the distal radius associated with distal radioulnar joint instability: a case report.

Torus fractures of distal radius are common in children and usually rendered stable and innocent. In this report, we present a case of distal radius torus fracture associated with distal radioulnar joint instability and emphasize the importance of the physical examination before and after roentgenographic evaluations.

A new radiographic measurement method for evaluation of tibial torsion: a pilot study in adults.

UNLABELLED: Computed tomography (CT) frequently is used to determine torsional abnormalities. However, its use in clinical practice may be limited. We present a new method for measuring tibial torsion using conventional radiographs. We compared the method with several clinical methods and with CT measurement in 44 lower extremities of 25 subjects. The radiographic method agreed well with all of the clinical methods, and this agreement was better than agreement between CT and clinical examination. The best agreement was between thigh-foot angle and the radiographic method. The proposed radiographic measurement is a practical method for evaluation of tibial torsion in outpatient clinics without the need for specialized equipment. LEVEL OF EVIDENCE: Level II, diagnostic study.

Simultaneous ipsilateral proximal interphalangeal and metacarpophalangeal dislocation of the fifth phalanx: A case report.

INTRODUCTION: There is no case of simultaneous ipsilateral proximal interphalangeal and metacarpophalangeal dislocation of a finger in the literature. CASE PRESENTATION: A 61 years old male patient sustained an ipsilateral dorsal dislocation of the PIP joint of his fifth finger and dorsal dislocation of the metacarpophalangeal joint. Closed reduction of proximal interphalangeal joint was achieved while open reduction of the metacarpophalangeal joint was carried out. CONCLUSION: The single most important element preventing reduction of the metacarpophalangeal joint was an interposition of the volar plate between proximal end of the phalanx and the head of the metacarpal.

Intraoperative dislocation of the prosthetic femoral head into the pelvis during total hip arthroplasty.

An 86-year-old woman with severe osteoarthritis and severe pain in her left hip underwent total hip arthroplasty. Intraoperatively, the 22 mm femoral head impinged on the anterior rim of the acetabulum during a reduction maneuver, and disengagement of the femoral head from the neck occurred with migration of the head over the pelvic brim along the inner table of the pelvis. This complication related with hip arthroplasty is underestimated by many orthopaedic surgeons.

Pyomyositis of tensor fascia lata: a case report.

INTRODUCTION: Pyomyositis is a disease in which an abscess is formed deep within large striated muscles. CASE PRESENTATION: We report the case of a 10-year-old boy who presented with fever and a painful hip and was subsequently diagnosed with pyomyositis of the tensor fascia lata. In children with clinical and laboratory findings of inflammation in the vicinity of the hip joint, the differential diagnosis includes transient synovitis, an early stage of Legg-Calvé-Perthes disease, infectious arthritis of the hip, rheumatologic diseases and extracapsular infection such as osteomyelitis. CONCLUSION: To the best of the authors' knowledge, this is the first report of pyomyositis of the tensor fascia lata. Although pyomyositis is a rare disease and the differential diagnosis includes a variety of other commonly observed diseases, pyomyositis should be considered in cases where children present with fever, leukocytosis and localized pain.

[The results of treatment in pediatric Monteggia equivalent lesions]. / Cocuklardaki Monteggia esdeger lezyonlarinda tedavi sonuçlari.

OBJECTIVES: We evaluated the results of conservative and surgical treatment of pediatric Monteggia equivalent lesions. METHODS: The study included 13 children (3 females, 10 males; mean age 8 years; range 4 to 13 years) who underwent treatment for Monteggia equivalent lesions. Seven patients (53.9%) had Bado type 1 and six patients (46.2%) had type 3 equivalent lesions. Two patients with type 3 equivalent lesions also had a lateral humeral condyle fracture. On presentation, one patient (7.7%) had radial nerve palsy. Primarily, closed reduction was attempted in all the patients except for one patient who underwent urgent debridement and irrigation for an open fracture-dislocation. Reduction was successful in eight patients (61.5%). Upon failure of closed reduction, four patients (30.8%) underwent surgery within the first 24 hours of injury. Functional assessment was made according to the Reckling's criteria. The mean follow-up period was 4.1 years (range 2 to 7 years). RESULTS: None of the patients had nonunion. Conservative treatment did not result in loss of reduction of the radius head or limitation in the range of motion of the elbow joint. Except for the patient with an open fracture-dislocation leading to a poor functional result, the results were good in all the patients receiving conservative or surgical treatment. One patient (7.7%) treated conservatively developed cubitus varus (5 degrees ) and posterior angulation (20 degrees ) of the ulnar fracture line. One patient treated surgically had limitation of supination (10 degrees ) without limitation of flexion or extension of the elbow joint. Accompanying radial nerve palsy in this patient disappeared in the postoperative third month. CONCLUSION: Closed reduction is the first choice of treatment in pediatric Monteggia equivalent lesions. Surgical treatment becomes necessary if closed reduction fails.

Fractures of the bilateral distal radius and scaphoid: a case report.

INTRODUCTION: Bilateral fractures of the distal radius and scaphoid are extremely rare injuries. CASE PRESENTATION: A patient with bilateral comminuted, displaced distal fractures of the radius and bilateral fractures of the scaphoid was treated via internal fixation of the scaphoid fractures with Herbert screws and internal fixation of the distal radius fractures with locked volar plating. CONCLUSION: Rigid internal fixation of distal radius and scaphoid fractures is mandatory to start early active rehabilitation of the wrist without the need for wrist immobilization with a plaster or external skeletal fixation.

Focal fibrocartilaginous dysplasia in the humerus.

Focal fibrocartilaginous dysplasia is an uncommon, benign bone lesion that causes deformity of the long bones in young children. It has most commonly been encountered in the proximal tibia, and very rarely in the long bones of the upper limb, that is, the proximal humerus, distal radius, ulna, and proximal phalanx. Only one case of focal fibrocartilaginous dysplasia of the proximal humerus has been reported previously. The present study reports two such additional cases that were diagnosed in late childhood. The clinical presentation and radiographic findings are described with an emphasis on the natural evolution of the disease. Limb-length discrepancy is anticipated in these children in the long-term follow-up and, therefore, surgical intervention should be considered in the treatment.