Burak Beksac

Avulsion fracture of the posterior cruciate ligament at the tibial insertion in a child: a case report.

The posterior cruciate ligament (PCL) avulsion fracture from its tibial insertion is a very rare condition in children. An isolated avulsion fracture of PCL in a child and its repair by open reduction and internal fixation with a screw is reported.

Regional migratory osteoporosis and transient osteoporosis of the hip: are they all the same?

We hypothesized that regional migratory osteoporosis (RMO) and transient osteoporosis of the hip (TOH) terms describe a common disease process. Therefore, based on our patient, we aimed to review the pathogenesis, diagnosis, and treatment of both diseases. The patient was a pregnant woman in her third trimester with sacral insufficiency fracture, which was shortly followed by migratory arthralgia of both hips and ankles in a proximal to distal direction. She was operated (core decompression) for both hips and ankles, and she was symptom free at 17th month. RMO and TOH have an unclear etiology, share the similar course, and bear a self-limiting nature. Both disorders may be the same clinical entity with a common pathogenesis. Probably, many of RMO patients were labeled as TOH, and therefore, RMO has been underrepresented. In conclusion, we think that both RMO and TOH describe a common disease process. Either the diagnosis is RMO or TOH, the management will be the same. Finally, the conservative treatment protocol is a better treatment modality and must be obeyed even in resistant cases.

Mid-term result of ceramic bearings in total hip arthroplasty

PurposeThe purpose of this study was to evaluate our clinical experience with ceramic-on-ceramic cementless total hip arthroplasty (THA) and complications after an average follow-up of more than eightxa0years.MethodsFrom January 2001 to December 2008, 540 THA with ceramic-on-ceramic bearings were performed in 448 patients (92 bilateral, 54 of which were operated simultaneously) with a mean age 49.9xa0years (range 18–84) by a senior surgeon. Pre-operative aetiological reasons were developmental dysplasia of the hip (DDH) in 205 hips, degenerative arthritis in 157 hips, avascular necrosis in 51 hips, rheumatoid diseases in 40 hips, posttraumatic arthritis in 40 hips, other reasons in 25 hips and revision surgery in 22 hips. Patients were evaluated with Harris hip score (HSS), and radiological findings of acetabular and femoral component loosening or osteolysis with ceramic bearing related complications like squeaking, liner and head fractures were recorded.ResultThe average duration of follow-up time was 8.2xa0years (range, five to 13.2). The main Harris hip score increased from 42.4 points preoperatively to 94.9 points at the time of last follow-up. We had one fracture of the ceramic head, 11 clicking and four squeaking; one of them was revised because of terrible squeaking due to acetabular liner fracture, the other three were seldom audible from the outside and followed conservatively. We did not observed loosening or osteolysis due to ceramic bearings at the time of the final follow-up.ConclusionOur study has demonstrated that ceramic-on-ceramic bearings can be used safely in different etiological problems. Incidences of noisy hips are becoming less frequent.

Medical photography: principles for orthopedics.

BackgroundMedical photography is used clinically for patient evaluation, treatment decisions, and scientific documentation. Although standards for medical photography exist in many branches of medicine, we have not encountered such criteria in publications in the area of orthopedics.PurposeThis study aims to (1) assess the quality of medical images used in an orthopedic publication and (2) to propose standards for medical photography in this area.MethodsClinical photographs were reviewed from all issues of a journal published between the years 2008 and 2012. A quality of clinical images was developed based on the criteria published for the specialties of dermatology and cosmetic surgery. All images were reviewed on the appropriateness of background, patient preparation, and technique.ResultsIn this study, only 44.9% of clinical images in an orthopedic publication adhered to the proposed conventions.ConclusionsStandards have not been established for medical photography in orthopedics as in other specialty areas. Our results suggest that photographic clinical information in orthopedic publications may be limited by inadequate presentation. We propose that formal conventions for clinical images should be established.

Tapered stems one-third proximally coated have higher complication rates than cylindrical two-third coated stems in patients with high hip dislocation undergoing total hip arthroplasty with step-cut shortening osteotomy

BACKGROUNDnThe results of cementless stems in total hip arthroplasty (THA) done because of congenital dislocation with step-cut osteotomy is not well known, particularly the influence of the design and the role of extent of porous coating. Therefore we performed a retrospective study to evaluate the mid to long-term results THA performed with a single type acetabular component and different geometry and fixation type stems with ceramic bearings in the setting of step-cut subtrochanteric osteotomy in high hip dislocated (HHD) patients. We asked if the stem type affect the outcomes in terms of (1) intra and postoperative complication rates (2) radiographic outcomes (3) prosthesis survival in step-cut subtrochanteric shortening osteotomy.nnnHYPOTHESISnThe type of the stem, whether cylindrical or tapered does not affect the outcome if the femoral canal fit and fill is obtained and the step-cut femoral shortening osteotomy is primarily fixed.nnnMATERIALS AND METHODSnForty-five hips in 35 patients with a mean follow up of 10 years (range, 7-14 years) were evaluated. The single type cementless cup was placed at the level of the true acetabulum, a step-cut shortening femoral osteotomy was performed and reconstruction was performed with two different types of tapered stem in twenty-two hips (Synergy™ and Image™ proximally coated, Smith and Nephew, Menphis, TN, USA) and one type of cylindrical stem (Echelon™ with 2/3 coated, Smith and Nephew, Menphis, TN, USA) in twenty-three hips. Harris hip scores (HHS) and a University of California Los Angeles (UCLA) activity scores were calculated for all patients and successive X-rays were evaluated regarding component loosening and osteolysis, along with complications related to bearing, step-cut osteotomy and stem types.nnnRESULTSnForty-one hips (91%) had good and excellent clinical outcome according to HHS. The mean UCLA activity scores improved from 3.2±0.6 points (range, 2-4) preoperatively to 6.3 points±0.5 (range, 5-7) at the latest follow-up. The mean femoral shortening was 36±10mm (range, 20-65mm). Four (9%) dislocations were observed. There were five (11%) intra-operative femoral fractures and three (7%) cases of non-union, which were observed in tapered stems. Cylindrical stems had superior neutral alignment primarily. With any stem revision as the end point, cylindrical stems had a higher survival rate (100%) than all tapered stems (82%; 95% confident interval [CI] 77-97%) at ten years. With any revision as the end point, the 10-year survival rate for acetabular component (Reflection-Ceramic Interfit) and for femoral components were 98% (95% CI, 85-99%) and 91% (95% CI, 78-97%), respectively.nnnCONCLUSIONSnThere were more implant related complications in HHD patients undergoing THA when tapered stems with 1/3 proximal coating were used to reconstruct a step cut osteotomized femur, compared to cylindrical stems 2/3 coated.nnnLEVEL OF EVIDENCEnIV, retrospective study.

Simple electrodiagnostic method for morton neuroma

Introduction: We describe a simple and quickly applied electrodiagnostic method for confirming the diagnosis of interdigital neuropathy caused by Morton neuroma (MN). Methods: Interdigital nerves II–III and III–IV were stimulated with surface electrodes simultaneously touching the lateral side of 1 toe and the medial side of the other. Recording was also made with surface electrodes. The results of 20 normal controls and 14 patients with MN were evaluated. Results: The amplitude and peak latency values elicited in the patients as well as the interside differences revealed an acceptable abnormality rate between 57.1% and 71.4%. Conclusions: Although the most popular and effective method of MN diagnosis is clinical evaluation supported by imaging, electrophysiological studies can, in selected patients, provide valuable information. Muscle Nerve 49: 193–197, 2014

Long-term retrospective study on the placement of the cementless acetabular cup and clinical outcomes in patients undergoing femoral head autografting for hip dysplasia and total hip arthroplasty

BACKGROUNDnPlacement of acetabular cup in the dysplastic hip is a challenging procedure. Using bulk femoral headxa0autograft to increase the bony coverage of the cup is one of the techniques, which have been described. Thexa0impact of cup position on cup and autograft survival is a controversial issue. We aimed to determine whether the position of cementless acetabular cup used in conjunction with femoral head autograft in dysplastic hips affected the autograft-host incorporation with its final radiographic appearance and the cup survivorship into the second decade.nnnMETHODSnThirty-eight dysplastic hips with varying Crowe types in 31 patients (30 women and one man) were included. The mean age was 47 years (range, 29-64 years) and the mean follow-up was 20.3 years (range, 14.8-25.9 years). The initial postoperative and final radiographs were evaluated. The survival rate of the cups was analysed using Kaplan-Meier statistics and the log-rank test. Multivariate analysis was used to evaluate the effect of variables (Crowe type, radiographic initial host bone coverage over the cup and position of the cup) on survivorship.nnnRESULTSnThe acetabular cups were positioned anatomical in 27/38 hips according to Ranawat measurement technique. Trabecular bridging at graft-host interface was seen in all cases at an average 22.1 months. Neither acetabular cup position nor initial host bone coverage over acetabular cup less than 50% had any significant effect on either cup survival or final radiographic appearance of the graft. The 20-year cup survival rate without aseptic revision was 66% (95 CI, 52%-84%). No revision was performed due to graft resorption.nnnCONCLUSIONnTwenty-year survival rate of the cementless cup combination with femoral head autograft showed no significant differences whether it was placed at high or anatomic hip centre. The final radiographic appearance of the autograft was not affected from either the cup location or the initial radiographic horizontal host bone coverage.

Total hip arthroplasty with step-cut subtrochanteric femoral shortening osteotomy in high riding hip dislocated patients with previous femoral osteotomy

BACKGROUNDnTo evaluate the long-term clinical and radiological outcomes of cementless total hip arthroplasty (THA) in high riding hip dislocated patients with previous proximal femoral osteotomy.nnnMETHODSnTwenty-one consecutive patients with a mean age forty-two years were treated with cementless THA Step-cut subtrochanteric femoral osteotomy was performed in all twenty-eight hips. Metal on polyethylene (MoP) and ceramic on ceramic (CoC) bearings were used in two different consecutive time periods. The mean follow-up time was twelve years. Harris hip score, limb length discrepancy, complications, union status of the osteotomy, survivorship of constructs were the criteria for evaluation.nnnRESULTSnThe mean Harris hip score improved from 39.5 to 88.7 points. The mean limb length discrepancy in unilateral cases decreased from 54.5xa0mm to 12.3xa0mm. The mean amount of femoral shortening was 37xa0mm. The mean union time was 3.5 months and there were no delayed union and non-union. There were three cup and two femoral revisions due to osteolysis in patients who had MoP. There was only one femoral revision in patients who had CoC. The Kaplan Meier survivorship with an end point of any revision of the stem and the acetabular component was 94% (95% CI, 75%-98%) and 92% (95% CI, 74%-99%) at ten years respectively.nnnCONCLUSIONSnTotal hip arthroplasty with subtrochanteric step-cut femoral shortening is a successful technique to improve the hip functions and reconstruct limb length discrepancy in young patients with proximal femoral deformities.

Management of Infected Total Joint Arthroplasty

Periprosthetic joint infection is one of the most challenging complications of total joint replacement surgery. Until very recently, the infection diagnosis was not clearly defined in the orthopaedic literature. This review outlines the new definition of periprosthetic joint infection, the utility of various clinical, serological and radiological tests in the prevention and diagnosis of infection. Treatment strategies and principles are also reviewed in the light of the current literature.