Adem Aydın

Bilateral congenital vertical talus with severe lower extremity external rotational deformity: treated by reverse Ponseti technique.

Congenital vertical talus, also known as congenital convex pes valgus, is a complex, rare, foot deformity that is resistant to conservative treatment. We report a case of bilateral congenital vertical talus with severe lower extremity external rotational deformity that was treated by means of a method of serial manipulations and casts. Although the initial manipulation and casting before surgical treatment is the current concept of idiopathic congenital vertical talus, a good result can be obtained by a well-organized conservative treatment with the help of patient compliance, so routine surgical release of the Achilles tendon may not be necessary in all cases.

Internal Splinting: A New Technique for Achilles Tendon Repair

Open surgical repairs of Achilles tendon ruptures may result in local wound healing problems. Various minimally invasive and percutaneous approaches have been defined to overcome this problem and they are being used with increasing frequency. We are describing a new technique called “internal splinting” that enables a strong repair and maintains the local healing tissue at the site of injury. We applied this technique to both mid-substance and distal Achilles tendon ruptures, and we combined the best features of both open and percutaneous techniques, including the use of larger diameter suture typically reserved for open tendon repair. We preserved the healing tissue, the paratenon, and the skin as in the percutaneous methods. We evaluated the first 24 patients and found that this technique is safe and the results are satisfactory.

Modelo experimental de osteoporose: comparação entre ovariectomia e toxina botulínica tipo A

Objective To evaluate whether Botulinum toxin-A (BTX-A) has a similar effect to that of ovariectomy (OVX) on bone regarding bone mineral densitometry. Methods A total of 51 female rats were randomly divided into three groups of 17 animals each. The rats in the first group formed the control group, without any surgical procedure (Group 1). Group 2 received BTX-A while Group 3 was subjected to OVX. A total of 8 IU of BTX-A was injected into the right femoral region of all rats in Group 2. At baseline and 14 weeks later, bone mineral densities (BMD) of the left and right femurs of all rats in both groups were measured. Results There was no statistically significant difference between the groups with respect to baseline BMD. At the 14th week the BMD of the right femurs were statistically significantly higher in Group 1 than other groups, although there was no statistically significant difference between Groups 2 and 3. The mean BMD results of the left femur in Group 3 were statistically significantly lower than the results in Groups 1 and 2 at the 14th week. Conclusion The results of the current study showed that BTX-A had a similar effect to that of OVX on osteoporosis regarding BMD. Evidence Level I, Experimental, Controlled, Animal Study.

Anterior knee dislocation with ipsilateral open tibial shaft fracture: a 5-year clinical follow-up of a professional athlete.

Traumatic dislocation of the knee joint is an uncommon complex, multiple ligamentous injury resulting from a high-energy trauma. Significant lack of functions can be seen because of both early and late complications of these injuries such as popliteal artery disruption, peroneal nerve injury, persistent instability and posttraumatic arthritis. Therefore, the emergency surgery is necessary due to possibility of neurovascular compromise and limb loss. Controversies over operative versus closed immobilization of traumatic complex, multiple ligamentous knee injury are still debated. We report a case of traumatic anterior dislocation of the right knee with an ipsilateral tibial shaft fracture in association with right popliteal artery occlusion of a professional athlete who was returned to his sports activity by surgical treated tibia fracture and conservative treatment of the knee dislocation.

Delayed reconstruction of quadriceps tendon rupture with Endobutton®: a new technique

Bilateral spontaneous rupture of the quadriceps tendon is an uncommon and serious injury that usually occurs in middle aged to elderly patients who have additional medical conditions such as rheumatoid arthritis, chronic steroid usage, and diabetes mellitus. Within this group, delayed treatment is an infrequent but difficult clinical situation. Fibrous degeneration, muscle contraction, and poor bone quality of the patient moved us to find new method for restoration. We report a modified technique for the surgical treatment of the spontaneous bilateral quadriceps tendon rupture in a patient with rheumatoid arthritis and chronic steroid usage. We performed only one tunnel to the patella by using 2.5-mm drill bit, and we used Endobutton® fixation device (Smith & Nephew, USA) for postfixation on the distal pole of the patella. In this way, it seems safer and may have low morbidity with multi-holes method for the risk of patellar fractures that occurs due to additional medical conditions such as rheumatoid arthritis and glucocorticoid-induced osteoporosis.

The effect of anterolateral ligament integrity on the tibia displacement and reaction forces of anterior cruciate ligament: A finite element model study

Objective: Recent studies focused on rotational instability and remained positive pivot test in patients with anterior cruciate ligament (ACL) reconstruction. Clinical, radiological and biomechanical studies showed the importance of the anterolateral ligament (ALL) integrity. ALL is one of the stabilization structures against the internal rotation of the tibia under forces which was associated with Segond fracture previously. Even some authors claimed that ACL failure and risk of re-rupture increased if only ACL reconstruction performed in patients with simultaneous ALL injury. The aim of the study is to evaluate the importance of ALL on knee biomechanics during anterior drawer test and internal rotation forces with different flexion angles in terms of reaction forces on ACL and the amount of tibia displacement via finite element analysis. Methods: Three dimensional (3D) solid model of knee joint and ALL injured models were constructed based on DICOM formatted computed tomography (CT) images. 0°, 15°,30°,45°,60°,75° and 90° flexion angles were applied respectively to reference models. Then varied anterior drawer and internal rotational forces were used to investigate the effect of ALL. ANSYS ®Version 17 was used in analyses and same boundary conditions were used in all models. Results: In critical analyzing the all results; medial displacement and the amount of anterior drawer distance were increased in all ALL injured models when compared with references. Therewithal the rotational displacements were increased by increasing the knee flexion angle and rotational torque. But, it was not a significant change in the amount of displacement between the models with respect to anteroposterior displacement when the anterior drawer force was increased. Conclusion: ALL particular has an important role in the stability of the internal rotation occurs against the force and with increased contribution rate to the knee joint stability by increasing the knee flexion angle. But the reaction forces were not affected by ALL integrity. So this study do not support the previous studies which suggest simultaneously reconstruction of both ligaments to avoid re rupture of ACL in cases with ALL injured.

A Case of Bilateral Suppurative Arthritis of Hip Joint with Concomitant Pyomyositis

Hip pain in a child is a common presentation and may pose a diagnostic challenge. Septic arthritis, transient synovitis, Perthes disease, and slipped capital femoral ephiphysis are the most important causes of hip pain among the children aged 3–10 years (1). Fracture, inflammatory arthropathy and tumors are other causes of hip irritability. Diagnosis of pyomyositis involving muscles around the hip may be problematic because of its rarity, its indolent presentation, and the similarity of its clinical features with those of septic arthritis. The differential diagnosis can be made on the basis of the history, physical examination and imaging studies. The problem often left to the clinician is to choose between septic arthritis and transient synovitis, the two most probable etiologies (2). A 7-year-old boy presented with a five-day history of pain in both hips. There was no history of trauma or any other apparent reason for the pain. He had been treated by a physician with oral cephalosporins for five days prior to his presentation. His family history was not contributory. The patient had a continuous temperature of 38.5°C and was unable to extend, abduct or rotate his hips because of the pain and kept them in 80° flexion. He had a white blood cell (WBC) count of 13.900/μL, an erythrocyte sedimentation rate (ESR) of 82 mm/hour and a C-reactive protein (CRP) of 5.51 mg/dL. Plain radiographs of the pelvis demonstrated no abnormalites. Ultrasound examination showed fluid collection in both hip joints. Magnetic resonance imaging (MRI) revealed pyomyositis of the left obturator externus and pectineus muscles with bilateral hip joint effusion, suggesting septic arthritis (Figure 1). Bilateral hip joint aspirate revealed a straw-colored fluid containing 18.356 WBCs/ μL (80% neutrophils, 15% lymphocytes, and 5% monocytes). Glucose concentration of the fluid was <20 mg/dL. The pathology of the tissue specimen revealed an exudate full of neutrophils and fibrin clusters. The Gram smear showed gram (+) stained cocci but no bacterial growth occurred in joint fluid cultures. Figure 1. MRI of the pelvis reveals pyomyositis of the left obturator externus and pectineus muscles with bilateral hip joint effusion suggesting septic arthritis Surgical drainage was performed through a posterior approach for both hips. There was exudative high viscosity joint liquid in both hips. Empiric intravenous clindamycin and cefazoline were started and continued for six weeks. Blood and pus cultures were positive for Staphylococcus aureus sensitive to clindamycin. Within days, the patient’s pain has ceased, together with the normalization of ESR and CRP concentrations. Four months after his discharge, he was asymptomatic and had full range of motion in both hips. Prompt and meticulous differential diagnosis of this patient, which included septic arthritis, transient synovitis, and pyomyositis as the most frequently encountered causes of hip pain, was critical because of the vastly different treatments and potential for sequelae of each clinical entity (3, 4). Eich et al. (5) concluded that a rectal temperature of ≥38°C, an erythrocyte sedimentation rate of ≥20 mm/hour, and a C-reactive protein concentration of ≥20 mg/dL (200 mg/L) were the most important characteristics for differentiation of septic arthritis and transient synovitis. If two of these parameters were positive and ultrasonography showed a hip effusion, there was a sensitivity of 100% and a specificity of 89% for septic arthritis. Whereas the normal-to-slightly high WBC count of our patient was not in favour of an infection, a body temperature of 38.5°C, neutrophil predominance in the peripheral smear, and elevated acute phase reactants might be suggestive of septic arthritis, although these laboratory parameters are very well known to lack a definitive diagnostic value. Furthermore, bilaterality of the symptoms made the diagnosis extremely difficult as bilateral septic arthritis is a rare condition (6). Luhmann indicated in their review that a previous antibiotic treatment may camouflage the clinical picture of septic arthritis (7), which should be the case for our patient, who had been on cephalosporins for a few days. Even if the patient were “antibiotic-free”, the chances that we could grow the causative organism would not be expected to be more than 30% (8). Thus, although the causative organism of the septic arthritis could not be identified, the clinical and laboratory findings pointed to the diagnosis without any suspicion. In addition to the unexpected finding of bilateral septic arthritis, another rarity was the association of pyomyositis, which was detected in the MRI. The most common etiologic organism is Staphylococcus aureus, but Streptococcus, Escherichia coli, and Enterococcus have also been reported (9). The pathophysiology of the pyomyositis is unclear and there is no clear evidence to the support trauma of the affected muscle with transient bacteremia theory, as in our patient’s history (10). In addition to symptoms and signs of osteomyelitis, cellulitis and malignant tumors; pyomyositis may manifest itself mimicking septic arthritis, which might have accentuated the clinical picture of our patient. The use of MRI in such cases is the mainstay of diagnosis. What we have learned from this case is that septic arthritis might be bilateral and that bilateral septic arthritis and pyomyositis should be considered in the differential diagnosis of children with hip pain.