Clinical and radiological outcomes of chronic severe slipped capital femoral epiphysis patients treated by surgical dislocation and modified Dunn osteotomy: Case series.

OBJECTIVES: This study aims to evaluate the clinical and radiological outcomes of patients with chronic severe slipped capital femoral epiphysis (SCFE) treated by surgical dislocation and modified Dunn osteotomy (MDO). PATIENTS AND METHODS: This retrospective study, conducted between January 2010 and December 2017, included nine patients (8 males, 1 female; mean age 12.6 years; range, 7 to 16 years) with nine hips. The degree of corrections in Southwick angle and alpha angle were measured on frog-leg views. Range of motion (ROM) of the hips was measured at each follow-up visit. Heyman and Herndon classification system and Harris Hip Score (HHS) were evaluated for clinical and functional outcomes at the latest follow-up visit. RESULTS: The mean follow-up time was 34.8 months. Avascular necrosis complication was observed in one hip. Except two patients with lateral femoral cutaneous neuropathy, none of the patients suffered from any other complications. Mean preoperative Southwick angle of 59.1° was corrected to an angle of -0.8° postoperatively. Alpha angles were calculated as 44.6° postoperatively. Modified Dunn osteotomy resulted in marked improvement in hip ROM in all directions and increased HHS. CONCLUSION: Our results encourage us to use this method in treating SCFE patients with chronic severe slips.

The analysis of functional and radiographic outcomes of conservative treatment in patients with low lumbar burst fractures.

INTRODUCTION: Burst fractures of the low lumbar spine constitute approximately one percent of all lumbar fractures. There is still no consensus on the optimal treatment of low lumbar burst factures. We aimed to evaluate the functional and radiographic outcomes of conservative treatment in patients with low lumbar burst fracture. METHODS: 15 patients (11 males, 4 females; mean age 32±8) who had low lumbar spine burst fracture treated with a custom-moulded thoracolumbosacral orthosis (TLSO) with a thigh extension were enrolled. The mean follow-up period was 22±6 months. 14 patients were neurologically intact and one had isolated nerve root injury. There were 24% type A fractures and 76% type B fractures according to the Denis classification system. Functional outcomes were evaluated by using Oswestry Disability Index (ODI), Short-Form 36 (SF-36) and Visual Analogue Scale (VAS). Radiographic outcome was analyzed by measuring anterior vertebral height loss, kyphosis angle, amount of canal retropulsion. Functional and radiographic outcomes were reviewed initially and at 1, 3, 6, 12 months, and at the latest follow-up. Functional and radiographic improvements were analyzed statistically. RESULTS: The mean bracing period was 11.9±1.7 weeks. The mean initial ODI, SF-36, and VAS score of the patients was 78.3±9.6, 23.7±8.9, and 8.7±0.7, respectively. The mean ODI, SF-36, and VAS score of the patients at the final follow-up was 26.4±6.5, 68.1±11.2, and 2.8±1.7, respectively. The improvement in functional outcomes was measured to be significant (p<0.05 for ODI, SF-36 and VAS). The mean initial anterior vertebral height loss, kyphosis angle, amount of canal retropulsion was found to be 27.2%±9.6%, -6.8°±3.2°, 37.4%±10.2%, respectively. The mean anterior vertebral height loss, kyphosis angle, and amount of canal retropulsion at the final follow-up was 23.1%±.6.7%, -4.2°±2.4°, 19.6%±7.7%, respectively. Among the radiographic outcomes, only the amount of canal retropulsion improved statistically (p=0.042). CONCLUSION: Conservative treatment using a custom-moulded thoracolumbosacral orthosis with a thigh extension is a safe and effective method in patients with low lumbar spine burst fractures and can improve functional and radiographic outcomes.

A novel technique for reconstruction of the medial patellofemoral ligament in skeletally immature patients.

Habitual or recurrent dislocation of the patella in the skeletally immature patient is a particularly demanding problem since the etiology is frequently multifactorial. The surgical techniques successfully performed in adults with patellar instability may risk injury to an open growth plate if applied to children. We present a technique that preserves femoral and patellar insertion anatomy of medial patellofemoral ligament (MPFL) using a free semitendinosus autograft together with tenodesis to the adductor magnus tendon without damaging open physis on the patellar attachment of MPFL. A 3-cm long longitudinal skin incision is performed 10 mm distal to the tibial tuberosity on the anteromedial side. The semitendinosus tendon is harvested with the stripper. The semitendinosus tendon is placed on a preparation board and cleaned of muscle tissue. The usable part of the tendon should be at least 20 cm long and 4 mm wide. The two free ends of the graft are sutured with Krakow technique. A medial longitudinal incision 2 cm in length is made to expose the MPFL and to abrade the patellar attachment of vastus medialis obliquus. The first patellar tunnel is created with 4.5 mm drill at the mid aspect of the medial patella in the anteroposterior and proximal-distal direction. The drill hole is formed parallel to the articular surface of the center of the patella. The second tunnel is created with 3.2 mm drill and the entry point is localized at the center of the patella. These two tunnels intersect to form a single tunnel. The semitendinosus autograft is run through the bone tunnel in the patella. Double-stranded semitendinosus autograft is placed in the presynovial fatty plane between the second and the third layer of the medial retinaculum, and tenodesis to adductor magnus tendon is applied by a moderate medial force with the knee flexed at 30°. Aftercare includes immobilization of the joint limited to 30° flexion using an above-knee splint for 2 weeks. No recurrent dislocation was observed in three patients (4 knees) at a mean follow-up time of 17.7 months. Both range of motion and radiological finding were restored to normal limits.

[Factors causing stiff knee after total knee arthroplasty]. / Total diz artroplastisi sonrasi diz sertligine neden olan faktörler.

OBJECTIVES: In this study, the factors causing stiff knee after primary total knee arthroplasty (TKA) in patients with medial compartment osteoarthrosis were evaluated. PATIENTS AND METHODS: Primary TKA surgery was performed in fifty-three knees in 48 patients (42 females, 6 males; mean age 67.2±8.5; range 59 to 76 years) diagnosed with medial compartment osteoarthrosis. Five patients (10%) out of forty-eight underwent bilateral primary TKA. In the patients who had bilateral TKA, the second operation was performed six months later. Patello-femoral arthroplasty was performed in none of the patients. In the final follow-up, the knees, which had more than 10° of extension limitation and less than 95° of flexion, were defined as post-TKA stiff knee. The patients who developed stiff knee were classified as group 1 and the patients who did not develop stiff knee were classified as group 2. The possible factors that may cause stiff knee after TKA such as age, gender, range of knee flexion and extension, flexion arc, tibiofemoral angle, tibial slope angle, the change in the height of the joint line, the length of the patellar tendon, the change in the American Knee Society scores, body mass index, and the sizes and positions of the components were evaluated and compared pre- and postoperatively within and between both groups. RESULTS: Stiff knee was found in eight knees of six patients (16%) after TKA. In group 1, the mean extension range was 14.9°±4.6° and the mean flexion range was 82.6°±7.4°. In group 1, among the factors that may cause knee stiffness; preoperative flexion range and American Knee Society scores were found to be significant (p=0.028 and p=0.036, respectively). The American Knee Society scores were observed to be significantly lower in group 1 when compared to group 2 postoperatively (p=0.018). CONCLUSION: If the preoperative flexion range is limited and the American Knee Society scores are low, then the stiff knee is more likely to occur in patients who will undergo TKA. Age, gender, tibiofemoral angle, tibial slope angle, the change in the height of the joint line, the length of the patellar tendon, and the sizes and positions of the components have no significant effect on the development of stiff knee after TKA.

Does timing matter in performing kyphoplasty? Acute versus chronic compression fractures.

The objective of this prospective consecutive cohort study was to compare the clinical outcomes, the radiographic outcomes and the complication rates of symptomatic acute (< 10 weeks) and chronic (> 16 weeks) osteoporotic vertebral compression fractures (VCFs) treated with kyphoplasty. Twenty-eight consecutive patients had 52 symptomatic osteoporotic VCFs treated with kyphoplasty; 5 of these patients were treated in two sessions. The Oswestry Disability Index (ODI) for back pain, a Visual Analog Scale for pain assessment, a patients' satisfaction scale, and medication usage served to evaluate the clinical outcomes. All these variables improved significantly in both groups, and more so in the acute group, but the difference was most often not significant. Vertebral height, local kyphosis angle, global sagittal alignment and dynamic fracture mobility significantly improved in both groups (except global sagittal alignment), and again more so in the acute group (except global sagittal alignment); the difference between groups was significant regarding radiological variables, except global sagittal alignment. Timing of kyphoplasty certainly matters, as the clinical and radiological outcomes were mostly better in acute fractures than in chronic fractures, which somehow responded satisfactorily. Controlled studies (kyphoplasty versus natural history) are needed to establish the real value of the procedure.

The treatment of Kienböck disease with vascularized bone graft from dorsal radius.

INTRODUCTION: Numerous surgical treatment options are proposed for the Kienböck disease but there has not been a consensus on the most appropriate method yet. The aim of this study is to present our experience and preliminary results of the use of vascularized bone graft from dorsal radius. MATERIALS AND METHODS: Second and third intercompartmental supraretinacular artery pedicled bone graft has been used to treat 11 patients with Kienböck disease between 2001 and 2006. The average follow-up period was 37 months (range 19-77 months). Pre- and post-operative range of motion, pain and grip strength, radiologic parameters such as carpal height ratio, Stahl index and scapholunate angle were evaluated. RESULTS: Eleven patients were composed of two stage II, one stage IIIA and eight stage IIIB patients according to Lichtmann classification. At the end of the observation period, five excellent, four good, one fair and one poor results were observed. There were no or little changes in carpal height ratio and Stahl index. Pain has diminished considerably. DISCUSSION: We believe that the treatment of Kienböck disease with vascularized bone graft from the dorsum of the radius has encouraging results and need no other additional procedures.

A pediatric case of pyomyositis presenting with septic pulmonary emboli.

Pyomyositis is a suppurative infection of skeletal muscle most commonly caused by Staphylococcus aureus. It is mainly encountered in children and immunocompromised. Eight year old previously healthy girl presented with confusion, fever and swelling of the right knee two days after a trauma. Abdominal ultrasonography and computerized tomography taken upon development of hematemesis revealed no pathology in the abdomen, but potential bleeding sites in lung sections. Thorax CT images were interpreted in favor of septic pulmonary emboli due to the presence of peripheral nodular consolidation areas with central cavitation, mostly pathchy in medial areas. S. aureus was isolated in the blood culture. At the end of third week of hospitalization, gadolinium enhanced contrast MRI of right extremity was taken to evaluate right extremity swelling and revealed abscess formation as expected in the clinical progress of pyomyositis. Pyomyositis and septic pulmonary emboli are a rare association. This case demonstrates that the high index of suspicion in pediatric cases with muscle findings and septic pulmonary findings and early institution of therapy may improve the prognosis.

[The modifed Eden-Lange procedure for paralysis of the trapezius muscle]. / Trapezius felcinde modifiye Eden-Lange prosedürü: Olgu sunumu.

Trapezius muscle paralysis results from injury to the spinal accessory nerve. Impairment in the trapezius muscle function may destabilize the muscle resulting in winged scapula. A 25-year-old university student who was active in sports had complaints of shoulder drop and pain on abduction. He had a three-year history of fall resulting in a scapular fracture for which he received conservative treatment. Physical examination showed asymmetry and drop of the right shoulder. Lateral scapular winging was apparent particularly above 90 degrees of abduction. Electromyography revealed isolated paralysis of the trapezius muscle. The patient underwent reconstruction with the modified Eden-Lange procedure. After a two-year follow-up, asymmetry in the shoulder decreased, there was no pain on active abduction, and the patient returned to active sports and was fully satisfied with the outcome.

Reconstruction of diabetic foot ulcers by lateral supramalleolar flap.

OBJECTIVE: To report a series of 8 diabetic patients in whom the reconstruction of large-sized defect of the foot was performed using lateral supramalleolar flap. METHODS: Coverage of the soft tissue defect was carried out by a lateral supramalleolar flap in 8 patients who had large-sized, non-healing ulcers at the Celal Bayar University, Department of Orthopedics and Traumatology, Manisa, Turkey, between 1998-2003. The mean age was 54 years. Preoperatively Doppler flowmeter evaluation was performed, and the ischemic index was calculated in all patients. RESULTS: The flaps survived except for one patient who had a large defect on the heel with low ischemic index. The average healing time of the ulcer region and recovery of regular walking status was 34 days. The average healing period of the donor site was 35 days. After the average follow-up period of 40 months, neither infection nor a recurrence of the ulcer was encountered. The major problem of the donor area was skin graft breakdown and its non-aesthetic appearance due to hypertrophic granulation tissue. CONCLUSION: The lateral supramalleolar flap is a reliable option for the reconstruction of large-sized diabetic ulcers involving the dorsal aspect of the foot. This can also be used in conjunction with local muscle flaps, such as abductor hallucis for covering deep and large heel defects when the sural neurocutaneous flap is contraindicated.

Synovial hemangiohamartomas of the knee joint.

Hemangioma or vascular malformation of the synovium is rare and presents a difficult problem in diagnosis and treatment. A long history of joint pain and recurrent non-traumatic hemarthrosis usually draws attention to the hemangioma of the knee joint. The lesion can be seen in two different formations; the synovial hemangioma or the arteriovenous malformation named as hemangiohamartomas, both of which involve the synovium and cause non-traumatic episodes of hemarthrosis. MRI scanning together with arthroscopy is a diagnostic tool to demonstrate the extent and the nature of the lesion. We treated the three patients at different ages. All patients underwent standard radiographic examination, CT scans, MRI and diagnostic arthroscopy. After frozen section taken via arthroscopically, the lesions were excised by arthrotomy. The mean follow-up was 38 months (31-45) and all patients are asymptomatic postoperatively. Three additional cases and a review of the literature are presented because of the rarity of the lesion.

[Osteotomies in the treatment of osteochondral lesions of the knee joint]. / Diz ekleminin osteokondral lezyonlarinin tedavisinde osteotomiler.

Excellent results of total knee arthroplasty have outweighed high tibial osteotomy applications in the treatment of osteoarthritis of the knee joint, but there is a growing interest in osteotomies as an adjunct in the treatment of full-thickness chondral and osteochondral lesions of the knee. Abnormal biomechanics in both tibiofemoral and patellofemoral articulations resulting from instability and malalignment should be corrected and osteotomy should be regarded as the first step in the treatment of these lesions. A simultaneous or staged osteotomy may contribute to the success of current techniques used for cartilage and osteochondral repair. Clinical, radiographic, and experimental studies have shown beneficial effects of osteotomies on cartilage regeneration. The aim of the osteotomy is simple: cartilage needs proper biomechanical environment for healing.

[Giant cell tumor at the wrist: a review of 23 cases]. / El bileginde dev hücreli tümör: yirmi üç olgunun incelenmesi.

OBJECTIVES: We evaluated patients who underwent surgical treatment for giant cell tumor of the wrist with regard to recurrence rates, factors influencing tumor recurrence, complications, and postoperative functional and emotional status of the patients. METHODS: The study included 23 patients (6 males, 17 females; mean age 31.6 years; range 12 to 74 years) who were treated surgically for giant cell tumor of the wrist. Grading, assessment of surgical margins, and functional evaluation were performed according to the Enneking's criteria. The effects of tumor volume, soft tissue extension, and selected surgical therapy on recurrence were investigated. Joint movements and stability, postoperative pain, presence of deformity, muscle strength, limitations in functional activities, and patient satisfaction were evaluated. The mean follow-up period was 6.7 years. RESULTS: Of all the patients, 69% had stage 2 and 23% had stage 3 tumors. There was no significant correlation between tumor volume and recurrence (p=0.22). Recurrences were observed in three (33%) of nine patients with soft tissue extension and in four (28.6%) of 14 patients without soft tissue extension. Recurrence rates were 33.3% in those who were treated by curettage alone (n=3), 50% with curettage and grafting (n=6), 50% with curettage and bone cement (n=2), and 16% in those who underwent wide excision (n=12). CONCLUSION: The most important factor influencing recurrence rate in giant cell tumors is the extent of surgical resection. At least marginal resection must be considered in patients with stage 2 and 3 lesions especially in cases with soft tissue extension. Adjunctive therapy should be added if curettage is considered.

Stiffness after total knee arthroplasty: prevalence, management and outcomes.

We investigated the prevalence of stiffness after total knee arthroplasty, and the results of the treatment options in our practice. Between 1987 and 2003, we performed 1188 posterior-stabilized total knee arthroplasties. The prevalence of stiffness was 5.3%, at a mean follow-up 31 months postoperatively. The average age was 71 years (range, 54-88). The patients with painful stiffness were treated by two modalities: manipulation and secondary surgery. In the manipulation group (n:46), the mean range of motion improved from 67 degrees before manipulation to 117 degrees afterward. This improvement was maintained at final follow-up as 114 degrees. There was no significant difference between the motion, immediately after manipulation and at final follow-up. However, motion at final follow-up was better for those manipulated early to those done later (p=0.021). In the secondary surgery group (n:10), the mean gain in motion was 49 degrees at final follow-up and average pain score was found 43. Patellar problems--component loosening and clunk syndromes--were found in 4 patients (40%). Early manipulation gives better gain of motion than done later and our patients had not lost flexion during follow-up. The patella should always be evaluated in every stiff arthroplasty. In our opinion, patellar problems are a good prognostic factor for the success of revision surgery and open arthrolysis does not correct a limited flexion arc, but it does relieve pain. Arthroscopic release is not reliable for severely stiff knees and we prefer to perform it in less painful and moderately stiff knees within 3 to 6 months after operation.

An unusual rotational injury: Pantibial ligamentous injury.

Pantibial ligamentous injury including knee dislocation and tibiotalar joint subluxation is an uncommon severe rotational injury. A 21-year-old male injured his right knee falling from a motorcycle. Physical examination revealed effusion on the right knee and ankle, and posterior translation of the tibia as well. The MRI of the right knee and ankle demonstrated the following findings: a complete disruption of cruciate ligaments, the medial collateral ligament, posteromedial corner injury together with a peripheric tear in the medial meniscus, the ruptured deltoid ligament, ankle syndesmosis space widening (>5 mm) and lateral subluxation of talus. Deltoid ligament of the right ankle was repaired and ankle syndesmosis was fixed with a cortical screw. The PCL and ACL were reconstructed arthroscopically with autogeneous bone-patellar tendon-bone graft. The midsubstance tear of MCL, posteromedial corner and medial meniscus tear were primarily repaired with nonabsorbable sutures. 3 years after the surgery, the patient was called for the final examination. MRI and X-ray findings of the knee and ankle joint demonstrated the continuity of ACL, PCL, MCL, and deltoid ligament. The patient, who is a farmer, can go back to his job and perform his daily activities. We presented a previously unreported case that involves both simultaneous occurrence of knee dislocation and tibiotalar joint subluxation. We used the term "Pantibial ligamentous injury" for this case.

The treatment of patellofemoral osteoarthritis with partial lateral facetectomy.

UNLABELLED: We investigated the impact of the partial lateral facetectomy of the patella on middle-aged to elderly patients with isolated lateral patellofemoral osteoarthritis. Between 1991 and 2000, we performed partial lateral facetectomy on 11 knees in 11 patients with an average age of 62 years (range, 53-72 years). The mean followup was 8 years (range, 3-14). The average Knee Society Score improved from a preoperative score of 150 to a score of 176 at latest followup. Followup radiographs showed slow progression of osteoarthritis in the patellofemoral and tibiofemoral compartments, but radiographic appearance did not always correlate with clinical symptoms. The success of this procedure depends largely on relief of pain. Partial lateral facetectomy is relatively simple and effective surgical treatment for middle-aged to elderly active patients with isolated lateral patellofemoral osteoarthritis who want to maintain activity level. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Tibiofemoral instability in primary total knee replacement: a review, Part 1: Basic principles and classification.

Tibiofemoral instability following total knee replacement has received little attention. However it is a cause of early and late failure and usually requires revision surgery. Several factors may be implicated including improper soft tissue balancing, flexion-extension gap mismatch and acute ligamentous injuries. Meticulous surgical technique and proper prosthetic selection at the primary procedure avoids this complication.

[Clinical results of lateral closing wedge high tibial osteotomy for osteoarthritis of the knee (Oblique osteotomy with tension band fixation)]. / Diz osteoartritinde lateral kapali kama yüksek tibial osteotominin klinik sonuçlari (Oblik osteotomi ve gergi bandi tespit teknigi).

OBJECTIVES: We evaluated the preliminary results of oblique and lateral closing-wedge high tibial osteotomy for medial compartment osteoarthritis of the knee. METHODS: Thirty-nine patients (29 women, 10 men; mean age 53 years; range 34 to 64 years) underwent oblique and lateral closing-wedge high tibial osteotomy followed by tension band plate fixation. According to the Ahlback system, seven patients had grade II, 27 patients had grade III, and five patients had grade IV osteoarthritis. Fixation was completed with a blade plate and two cortical screws. The results were evaluated using the Knee Society Score at the end of a mean follow-up of 23 months (range 12 to 41 months). RESULTS: The mean pre- and postoperative Knee Society scores were 43 (range 18-72) and 80 (range 20-90), and the mean Knee Function scores were 57 (range 45-90) and 72 (range 35-90), respectively (p<0.05). The mean preoperative deviation from the mechanical axis of the leg was 8.9 degrees varus (range 3 to 15 degrees). A mean correction of 11.6 degrees valgus (range 7 to 18 degrees) was afforded in order to obtain a slight valgus alignment. The mean postoperative femorotibial angle was 171 degrees (range 162-183 degrees). Complications were seen in 11 patients, which included severe overcorrection, fixation failure, transient nerve palsy, or pain over the fibular osteotomy site. CONCLUSION: Oblique high tibial osteotomy combined with tension band fixation is an effective procedure providing secure and durable fixation to allow early motion. It should be recalled that a high complication rate is likely during the learning curve, which adversely influences the clinical results.

[Giant-cell tumors of the tendon sheath involving the hand or the wrist: an analysis of 141 patients]. / El ve el bileginde tendon kilifinin dev hücreli tümörü: 141 hastanin degerlendirilmesi.

OBJECTIVES: Giant-cell tumors of the tendon sheath localized in the hand or wrist were retrospectively reviewed with respect to diagnosis, surgical treatment, and postoperative complications. METHODS: During a 21-year period, a total of 141 patients (83 females, 58 males; mean age 37.5 years; range 6 to 77 years) underwent surgery for 146 lesions that developed in the hand (n=134) or the wrist (n=12). Involvement was on the right side in 77 patients, and on the left side in 64 patients. The mean follow-up period was 3.5 years (range 6 months to 11 years). RESULTS: On presentation, the most common symptom was the presence of a painless soft tissue mass. The most frequent localization was the volar part (76%) of the second (27%) and the third (24) fingers, or the proximal phalanx (57%). Forty per cent of tumors were encountered at ages between 30 and 50 years. The duration of symptoms ranged from one month to five years and the highest number of presentations fell within the first six months. In eighteen patients, radiologic studies showed osseous involvement, being cortical sclerosis in 12 patients, and erosion in eight patients. Postoperative complications included digital nerve injuries in four patients, superficial infection in three patients, and joint stiffness in 12 patients. Twenty-three patients (16%) developed recurrences within a mean of 3.7 years (range 2 months to 7 years). CONCLUSION: Taking high rates of recurrences into consideration, surgery for giant-cell tumors of the tendon sheath requires wide surgical exposure, attentive skills, and the use of magnification.

The incidence and location of corona mortis: a study on 75 cadavers.

We dissected 150 fresh cadaver halves by ilioinguinal exposure, and counted all vessels more than 2 mm in diameter, connecting the obturator system to the external iliac system. The distance between the symphysis pubis and the anastomotic vessels was measured. We found vascular anastomoses between the obturator and external iliac systems in 91 of 150 sides (61%), and anastomotic veins in 78 of 150 exposures (52%). Arterial connections were seen in 29 of the exposures (19%). The mean distance between the anastomotic arteries and the symphysis pubis was 64 (45-90) mm, and 56 (37-80) mm for the communicating veins. There seemed to be no significant difference between genders in the incidence of corona mortis and the distance between communicating vessels and the symphysis pubis.