Coloarticular fistula following hip arthroplasty: A report of two cases.

Coloarticular fistulas extending to the hip joint are rare and serious pathologies causing morbidity and mortality due to sepsis. Herein, we present two cases with rarely seen coloarticular fistula complications following hip arthroplasty operations. One is with extracting gas from the cutaneous fistula after multiple revision total hip arthroplasty operations and one is after bipolar hip hemiarthroplasty with radiation therapy as a possible etiological factor. These reports emphasize that the drains must be followed for a possible color change and air uptake due to intestinal gas content after infected hip arthroplasty operations.

The effect of video-assisted discharge education after total hip replacement surgery: a randomized controlled study.

This study aimed to investigate the effect of a video-assisted discharge education program on activities of daily living, functionality, and patient satisfaction following total hip replacement (THR) surgery. This study included 31 patients who were randomly divided into the physiotherapy group (n = 18), and the video-assisted discharge education (VADE) group (n = 13). Both groups received a physiotherapy program. The VADE group was also received the VADE program. Face-to-face instruction was used in all of the educational programs. There was a significant difference in favor of the VADE group in Harris Hip Score, Nottingham Extended Activities of Daily Living Scale's movement score, Tampa Scale of Kinesiophobia, Patient Satisfaction Questionnaire (p < 0.05). There was a significant difference between groups on resting pain levels in the first week and on resting and activity pain levels in the third month in favor of the VADE group (p < 0.05). The results of this study demonstrated that VADE can be effective in improving patient satisfaction and functionality, reducing pain and kinesiophobia following THR.

Pediatric tibial shaft and distal metaphyseal fractures.

OBJECTIVES: This study aims to investigate the effects of associated factors like age, fracture level, accompanying fibular fractures and wound condition on healing by determining and comparing union scores of pediatric tibial fractures (PTFs). PATIENTS AND METHODS: Forty-five patients with 46 PTFs (32 males, 13 females; mean age 9.5 years; range 2 to 16 years) who were treated by closed reduction and casting or operated between January 2016 and January 2019 were retrospectively evaluated. The union scores were evaluated at the end of fourth, sixth and eighth weeks and compared to each other. Effects of the age, associated fibular fractures, wound condition, fracture level and treatment type to union score were analyzed. RESULTS: Twenty-eight (60.9%) out of 46 PTFs had associated fibular fractures and 18 (39.1%) did not. Motor vehicle accident was the most frequent etiologic factor (47.8%). Thirty-four out of 46 fractures were closed tibial fractures (73.9%) and 12 had open wound (26.1%). There was a negative correlation between age and the union scores (p<0.001 for each week). No significant difference was observed between the union score of diaphyseal and metaphyseal fractures at the fourth, sixth, and eighth weeks. The union scores of each week were higher in the conservative group compared to operative group (p<0.001 for each week). Associated fibular fracture group had lower union scores compared to isolated tibial fracture group at fourth, sixth and eighth weeks. Likewise, the union scores of the open fracture group were lower than the closed fracture group (p<0.05 for each week). CONCLUSION: Associated fibular fractures, open fractures and aging negatively affect union scores of PTFs. Attention should be paid, particularly in these conditions, during the selection of the operation type and the follow-up period of PTFs.

Stepped osteotomy of femoral head autograft for acetabular reconstruction in total hip arthroplasty for dysplasia of the hip: 3 to 12 years' results.

OBJECTIVES: This study aims to describe a stepped osteotomy technique applied to the femoral head autograft to keep the graft volume at a sufficient level, provide primary stability, and direct cancellous-cancellous bone contact. PATIENTS AND METHODS: In this retrospective study, 24 hips of 20 patients (5 males, 15 females; mean age 53 years; range, 43 to 68 years) with dysplasia of the hip (DDH) who underwent total hip arthroplasty with femoral head stepped osteotomy technique were evaluated between April 2003 and June 2010. Patients' age, gender, operation side, and postoperative complications were recorded. Aseptic loosening of the acetabular cup and graft integration/resorption were evaluated radiographically. Radiological evaluations were performed according to the methods of DeLee and Charnley, and Mulroy and Harris. Functional status of the patients was determined according to the criteria of Merle d'Aubigné and Postel, and Harris hip score (HHS). RESULTS: The mean follow-up period was 5.5 years (range, 3 to 12 years). None of the patients had any complications in the early postoperative period. In all patients, the percentage of acetabular component coverage by the graft was measured as 27% (range, 19 to 38%) on average. At the last follow-up, all patients were satisfied with the result and there was no sign of clinically loosening, osteointegration was complete, and there was no radiographic evidence of graft resorption or collapse of any hip. The overall Merle d'Aubigné scores and HHSs of the patients significantly improved at the final follow-up. CONCLUSION: This stepped osteotomy technique increases the probability of osteointegration, reduces the need for early revision, and provides reliable stability with satisfactory clinical and radiological midterm results.

Results of Peroneal Tendoscopy With a Technical Modification.

BACKGROUND:: The aim of this study was to evaluate the role of tendoscopy in the diagnosis and treatment of peroneal tendon (PT) pathologies, and to evaluate the results of our technical modification. METHODS:: Twenty ankles of 18 patients with retrofibular pain, operated on between 2006 and 2012, were included in this study. Peroneal tendoscopy was performed diagnostically for the patients who were diagnosed as having "peroneal tendinopathy" with physical examination, x-ray, or magnetic resonance imaging (MRI). After being diagnosed by peroneal tendoscopy, patients were definitively treated with either tendoscopy or open surgery. RESULTS:: Thirteen of 20 ankles had accompanying ankle pathology with PT pathology, and the other 7 ankles had no concomitant pathology. We detected peroneal tenosynovitis (PTS) in 13 patients, PT tear in 7 patients, and vincula thickening in 1 patient. The American Orthopaedic Foot & Ankle Society (AOFAS) score was 76 preoperatively, and after 2 years' follow-up the AOFAS score was 96. CONCLUSION:: Tendoscopy is a useful method for the diagnosis and treatment of PT pathologies. The patients with clinical suspicion of PT pathology were treated or diagnosed by peroneal tendoscopy with our technical modification. LEVEL OF EVIDENCE:: Level IV, retrospective case series.

Evaluation of the lateral instability of the ankle by inversion simulation device and assessment of the rehabilitation program.

OBJECTIVES: To assess the correctibility of the muscle atrophy, proprioceptive loss, and slowing of the reflex arc around the ankle after ankle sprain with rehabilitation. METHODS: The study group consisted of 20 cases with chronic instability who had at least two episodes of ankle sprains (mean 20.6 years, range 16-32 years); control group consisted of 20 patients with same demographic characteristics but without instability. Isokinetic muscle strength measurements and proprioceptive evaluations were made using the Cybex device before and 1.5-month after rehabilitation period. Additionally, the inversion simulation device, which was developed together with the mechanical engineering department of our university, was correlated with the EMG device, and response periods of muscles to stimulation were measured. RESULTS: The proprioceptive loss present in all cases with ankle instability before treatment significantly improved after effective rehabilitation (p=0.001). It was detected that lengthened peroneal latent periods shortened with effective rehabilitation (p=0.001). Cross-interaction of rehabilitation was shown with the preservation of the difference between the pathologic and normal sides regarding proprioception and peroneal latent periods before and after treatment, without any difference between the control group and the pathologic sides. CONCLUSION: After ankle sprains, especially in patients with chronic instability, strengthening of the muscles around the ankle with well-planned proprioceptive exercises helps the patients return to normal living and sports activities, and prevents unnecessary surgery, especially in cases with functional instability.

Effect of joint motion on safety of portals in posterior ankle arthroscopy.

PURPOSE: The purpose of this study was to determine the anatomic relation of the neural structures posteriorly crossing the ankle by use of classical ankle arthroscopy posterior portals and hindfoot endoscopy portals. The effect of ankle and hindfoot motions on portal-nerve distance was also determined. METHODS: This study included 20 feet and ankles in 20 adult volunteers who had no complaints regarding their ankle joints. To obtain 6 fixed positions of the ankle and hindfoot (neutral-neutral, neutral-varus, neutral-valgus, dorsiflexion-neutral, dorsiflexion-varus, and dorsiflexion-valgus) during magnetic resonance imaging examination, feet were positioned in a polycaprolactone splint that was shaped before examination. Magnetic resonance imaging examinations were performed at all 6 positions, and the shortest distance between the sural and posterior tibial nerves to the portals was measured at 2 different levels. RESULTS: The mean distance between the posterior tibial nerve and the posteromedial portal was 16.5 +/- 5.6 mm and that between the sural nerve and the posterolateral portal was 13.1 +/- 3 mm at the hindfoot portal level. At the level of the posterior ankle arthroscopy portal, the mean distance from the posterior tibial nerve to the posteromedial portal line was 13.3 +/- 4.6 mm and that from the sural nerve to the posterolateral portal line was 9.7 +/- 2.9 mm. The differences in distances were statistically significant (P < .001) according to the paired t test. We determined that the sural nerve approached the posterolateral portal in the dorsiflexion-varus (P = .026), dorsiflexion-valgus (P = .014), dorsiflexion-neutral (P < .001), and neutral-varus (P = .035) positions, and all differences were statistically significant. CONCLUSIONS: We found that the posterior medial and lateral portals created at the level of the tip of the fibula as described by van Dijk et al. while the foot was in a neutral-neutral position provided the greatest margin of safety. We found no advantage of placing the ankle and hindfoot in different positions to avoid neurologic complications. CLINICAL RELEVANCE: These findings suggest that neurovascular structures draw away from the posterior portals of ankle arthroscopy distally; by lowering the level of portals toward the tip of the fibula and positioning the foot at neutral, arthroscopic surgeons will decrease the risk of iatrogenic lesions.

Arthroscopic treatment of anterolateral soft tissue impingement of the ankle: evaluation of factors affecting outcome.

PURPOSE: To evaluate the results for patients treated arthroscopically for anterolateral soft tissue impingement syndrome, to determine the factors affecting the outcome, and to report on a synovial shelf. TYPE OF STUDY: Retrospective clinical review. METHODS: Forty-one patients underwent operative arthroscopy for anterolateral impingement of the ankle between 1990 and 2001; the mean follow-up was 83.7 months (range, 21 to 152 months). There were 25 men and 16 women with an average age of 33.2 years (range, 15 to 63 years). All patients reported a history of inversion injury to the ankle. The most frequent preoperative complaints were tenderness localized to the anterolateral aspect of the ankle, swelling, crepitation, and pain at weight-bearing. All patients had failed to respond to at least 3 months of conservative treatment. The results were assessed according to Meislin's criteria and the American Orthopaedics Foot and Ankle Society (AOFAS) scoring table. For statistical analysis, the Mann-Whitney U test was used where appropriate and the significance was set at P < .005. RESULTS: According to Meislin's criteria, there were excellent results in 21 patients, good in 16, fair in 2, and poor in 2. The mean AOFAS score was 89.6 points (range, 60-100) at follow-up. Four different soft tissue pathologies causing impingement were described. It has been statistically shown that cartilage damage located at the anterolateral region of the ankle and not advanced to the subchondral bone, and repeated inversion injuries had negative effects on clinical results at long-term follow-up. CONCLUSIONS: The arthroscopic diagnosis and treatment of anterolateral soft tissue impingement is a safe and effective method. Any combination of associated intra-articular pathologies, such as a chondral lesion or a new inversion injury of the ankle, after the arthroscopic procedure resulted in a poor outcome. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Irreducible posterolateral knee dislocation resulting from a low-energy trauma.

A small amount of knee dislocations is included in the irreducible knee dislocations group. In such instance, medial femoral condyle is buttonholed through the gap formed by medial retinacular and capsular structures and this prevents reduction. In this study, we present two cases in which there were irreducible posterolateral knee dislocations resulting from a low-energy trauma. In both cases, dimple sign produced by the invagination of the medial retinacular structures and capsule and ecchymosis medially were noted. Soft tissue invaginated between the trochlea and intercondylar notch was extracted by open reduction.

Is there any effect of suprascapular notch type in iatrogenic suprascapular nerve lesions? An anatomical study.

This anatomical study, which is aimed at assessing the effect of suprascapular notch type in iatrogenic suprascapular nerve lesions in surgical interventions, was conducted in two stages. A hundred dry scapulas and 20 scapulas of 11 cadavera were classified according to Rengachary. The point of measurement was determined medially as the deepest point of suprascapular notch and laterally as supraglenoid tubercle in dry scapulas and anchor of biceps in cadavera. It was found that in the measurements made in dry scapulas, notch Type-IV scapulas, despite not being statistically significant, had the lowest average (2.35 cm), with minimum and maximum values of 2.1 cm and 2.78 cm respectively, when compared to other scapula types. It was found in the cadavera study that the measurements of one Type-IV scapula and one Type-V scapula were lower than the other types. Determination of the notch type in the rotator-cuff tears--especially in massive and retracted tears where supraspinatus has to be released from the fossa--may be helpful in avoiding iatrogenic nerve lesion.

A different treatment modality for trochanteric fractures of the femur in surgical high-risk patients: a clinical study of 44 patients with 21-month follow-up.

INTRODUCTION: To assess the effectiveness of a modular axial fixator as an alternative method in surgically high-risk patients with trochanteric fractures of the femur. MATERIALS AND METHODS: In a prospective, uncontrolled clinical study, 44 high-risk patients (ASA grade 3 or 4) with trochanteric femoral fractures were treated by a modular axial fixator. They were prospectively followed up for 21 months (range 14-30 months) and evaluated using Foster's criteria. RESULTS: All of the fractures healed, and mean time to union was 10.9 weeks. Three types of complications were noticed. These were infections, varus alignment and shortening. Results were anatomically excellent in 35 patients, good in 9, and functionally excellent in 36, good in 8. CONCLUSION: The modular axial fixator is a reliable alternative for treating frail patients with trochanteric fractures of the femur.

Intrathoracic migration of Steinman wire.

We report two cases of intrathoracic migration of Steinman wire used for the treatment of the fracture and shoulder dislocation. The migrations were symptomatic with back pain in our cases. The treatment involved removing of the pin via thoracotomy. The postoperative course was uneventful. Intrathoracic migration of Steinman wires should be expected in fixation of the shoulder problems. To avoid this complication, threaded pins have to be used in surgery of the shoulder region.

The role of bone scintigraphy in determining the etiology of heel pain.

In this study we aimed to determine the role of bone scintigraphy as an objective diagnostic method in patients with heel pain. 67 heels of 50 of 182 patients with defined features who attended the orthopedics outpatient clinic with heel pain over a 3-year period, were treated with combined methods such as nonsteroidal anti-inflammatory drugs (NSAID) and contrast baths, stretching exercises and changing of footwear habits. A one year follow-up was established. The criteria identified by Wolgin et al. were used in assessing the results of the treatment. Subcalcaneal spur was demonstrated by radiography in 44 of the 67 heels. There were two different imaging patterns observed on three phase bone scintigraphy. Type I imaging pattern: Focal increased activity in the heel region or normal activity on dynamic and the blood pool phases and focal increased activity at the inferior calcaneal surface in the late static phase. Type II imaging pattern: Diffuse increased activity along the plantar fascia in the dynamic and the blood pool phase, and focal increased activity at the inferior calcaneal surface in the late static phase. There were 34 (50.7%) type I and 18 (26.8%) type II imaging patterns on the scans. Type I and type II imaging patterns were described as osseous and fascial respectively. At the final examination, the results for pattern type I were good in 16 patients (66.7%), fair in 6 patients (25%) and poor in 2 patients (8.3%), whereas in pattern type II results were good in 12 patients (80%) and fair in 3 patients (20%). The recurrence frequency was 4.1% and 6.6%, respectively. Subcalcaneal spur was determined in 70.5% of the patients with osseous pathology and 55.5% of the patients with fascial pathology. Based on this result, it can be ascertained that calcaneal spurs develop during the pathological process causing heel pain. Other findings supporting this claim were the differences in symptom periods of the patients with type I and type II imaging patterns and scintigraphies were normaly in 10 of 44 heels indicating subcalcaneal spurs on radiographies. These findings suggested that metabolic changes contributing to subcalcaneal spur were complete. Three phase bone scintigraphy is an objective method which can be used to diagnose heel pain, especially when determining the etiological factors and prognosis.

The reference point to measure the anterior intermeniscal ligament's thickness: an MRI study.

The purpose of this study was to identify a reliable reference point for measuring anterior intermeniscal ligament thickness and to investigate the morphological characteristics of the ligament at its attachment site to anterior horns of both menisci by MRI. MRI was performed in 98 knees of randomly chosen patients. The anterior intermeniscal ligament was detected in 61 knees (62.2%). The average ligament length was 29.8 mm. Men had significantly longer anterior intermeniscal ligament than women patients (32.5 vs. 27.8 mm). The thickness of anterior intermeniscal ligaments at their attachment sites to menisci was usually less than 3 mm; a thickness of 3 mm or more at the attachment site to anterior horns of the meniscus was defined as "cordlike." It is suggested that the "cordlike" pattern is a variation of the anterior intermeniscal ligament's attachment characteristics, and that this might have a significant role in meniscal translations during knee motion, and also that the "cordlike" pattern could be clinically important with respect to its relationship to the anterior horn of medial meniscus. The attachment site of the ligament is a reliable reference point for measuring its thickness.

Tarsal tunnel syndrome - the effect of the associated features on outcome of surgery.

Between 1989 and 2000, 16 patients underwent surgery for tarsal tunnel syndrome; 12 patients (13 feet) were available for follow-up at a mean of 83 (12-143) months. The symptoms had resolved in six feet, were improved in four, were unchanged in two and recurred after five years in one. Better results are obtained in patients who have space occupying lesions than in those in whom the aetiology is idiopathic or post-traumatic or those with foot deformities.

[Treatment of intertrochanteric femoral fractures with the use of a modular axial fixator device]. / Intertrokanterik femur kiriklarinin modüler aksiyel fiksatör ile tedavisi.

OBJECTIVES: Intertrochanteric femoral fractures are usually encountered in the elderly, leading to morbidity and even mortality due to age-related systemic complications. In this study, we evaluated the use of a modular axial fixator device in the treatment of intertrochanteric femoral fractures. METHODS: Intertrochanteric femoral fractures of 25 patients (18 females, 7 males; mean age 70 years; range 18 to 91 years) were treated by the use of a modular axial fixator. The fractures were classified according to the Boyd-Griffin classification. Surgery was performed after a mean of 5.76 days following trauma. The patients were allowed to walk using crutches on the second postoperative day and a single crutch after sufficient callus formation was radiologically determined. Final evaluations were made by the Foster's classification. The mean follow-up was 12 months (range 6 to 24 months). RESULTS: The mean operation duration was 34 minutes. Union was achieved in all patients after a mean of 12.3 weeks (range 9 to 18 weeks). Three patients (12%) developed varus deformity of 3, 5, and 9 degrees, respectively. Shortening in a range of 1 cm to 1.5 cm was detected in three patients (12%). Postoperatively, 10 patients developed pin tract infections, none of which required revision or removal of the fixator. Final evaluations yielded excellent and good anatomical results in 72% and 28%, and functional results in 80% and 20%, respectively. CONCLUSION: Reducing both the operation time and the immobilization period is of vital importance particularly in elderly patients with intertrochanteric femoral fractures. Due to its short length, the modular axial fixator offers significant advantages including higher tolerability, rapid weight bearing allowance, and achievement of union without seriously complicating events.

[The relationship between the thickness and elasticity of the heel pad and heel pain]. / Topuk yag yastigi kalinligi ve elastisitesi ile topuk agrisi arasindaki iliski.

OBJECTIVES: We investigated the factors affecting the thickness and elasticity of the heel pad and sought relationship between the heel pad thickness and elasticity and heel pain. METHODS: Of 182 patients who presented with a complaint of heel pain over a three year period, 50 patients (38 females, 12 males; mean age 46 years; range 23 to 73 years) met specific criteria for the study. A combined treatment modality was conducted throughout a year which consisted of non-steroidal anti-inflammatory drugs, contrast baths, stretching exercises, and changes in footwear design. At the end of a year, the results were assessed according to the criteria proposed by Wolgin et al. Measurements of heel pad thickness were performed according to the technique described by Jorgensen: compressibility index of the heel pad was calculated on anteroposterior and lateral radiographs of the heel, loaded and unloaded by body weight. RESULTS: The results were good in 35 patients (70%), fair in 12 patients (35%), and poor in three patients (6%). Four patients (8%) developed recurrences. Increased heel pad thickness, decreased elasticity, and delayed healing were observed in males, in patients above 40 years of age, in obese patients, in those with a pretreatment symptom duration exceeding 12 months, and in those with a greater subcalcaneal spur. CONCLUSION: The thickness of heel pad increases in relation to age and weight, resulting in decreased elasticity. In addition, subcalcaneal spur may be involved in heel pain induction through decreasing heel pad elasticity.

[Long-term functional results of adult intra-articular distal humeral fractures treated by open reduction and plate osteosynthesis]. / Açik redüksiyon ve plakli osteosentez ile tedavi edilen eklem içi distal humerus kiriklarinda uzun dönem fonksiyonel sonuçlar.

OBJECTIVES: We assessed the long-term functional results of surgical treatment of distal intra-articular humeral fractures, together with the factors having influence on the outcome. METHODS: Thirty-four patients (25 males, 9 females; mean age 38 years; range 20 to 78 years) who were treated by open reduction and plate osteosynthesis were retrospectively evaluated. All fractures were type C according to the AO classification. Five patients had open fractures. Thirty-three patients had surgery within the first two days after trauma. Posterior (n=19), lateral (n=13), and lateral and medial (n=2) incisions were used. Intra-articular olecranon osteotomy was performed in 11 patients in whom a posterior incision was used. The mean follow-up period was 81.5 months (range 24 to 141 months). Functional evaluation was made according to the criteria described by Jupiter et al. RESULTS: Postoperative complications included infection in four patients, nerve lesion in four patients, nonunion of the olecranon in one patient, and fixation failure in one patient. The mean elbow flexion was 115.1 degrees, and the mean extension loss was 26.3 degrees. Four patients had severe pain and deformities. According to the criteria by Jupiter et al., the results were excellent in six (17.7%), good in 15 (44.1%), fair in nine (26.4%), and poor in four (11.8%) patients. The rate of excellent and good results were higher in closed fractures, in males, in patients at 20 to 40 years of age, in those undergoing posterior incisions and intra-articular olecranon osteotomy, and in patients in whom double-plate osteosynthesis was used. CONCLUSION: Our results suggest that age, gender, infection, preservation of neural function, successful rigid fixation, an anatomic restoration of the joint surface, and early rehabilitation are effective factors on the functional outcome.