Cem Nuri Aktekin

Immediate incorporated hip spica casting in pediatric femoral fractures: comparison of efficacy between normal and high-risk groups.

Background: Immediate hip spica casting is the most commonly used method for the treatment of pediatric femoral fractures. The main disadvantage of the method is the unacceptable shortening (>25 mm), which may occur during the treatment. Buehler et al described the so-called telescope test to identify the cases with a relatively high risk of unacceptable shortening. On the basis of this test, patients with an overriding of the fracture ends of more than 30 mm have a 20.4 times higher risk of unacceptable shortening compared with those with an overriding of less than 30 mm. This relatively higher risk of unacceptable shortening may be avoided by a hip spica cast, which is incorporated to a distal femoral traction pin. Methods: The study consists of 47 (26 boys and 21 girls) patients. Mean age was 40.3 months (range, 18 months to 6 years). Patients were divided into 2 groups according to the telescope test. Group 1 included patients with telescope test results of more than 30 mm. Group 2 included patients with telescope test results of 30 mm or less. All patients were treated with a hip spica cast, which is incorporated to a distal femoral traction pin within 8 hours of the initial trauma. During cast treatment, patients were followed up by weekly x-ray controls for the first month. Patients were assessed for unacceptable shortening and misalignment. Results: Mean (SD) shortening during cast treatment was 2.9 (5.1) mm on the treated site. Shortening was detected in 16 patients (88.9%) in group 1 and in 7 patients (24.1%) in group 2. A significantly higher number (P < 0.001) of patients developed shortening in group 1. However, unacceptable shortening (>25 mm) did not develop in any patient in both groups. There was no significant frontal plane malalignment in both groups (P > 0.05). Sagittal plane malalignment was significantly higher in group 1 (P < 0.05). Conclusions: Hip spica cast, which is incorporated to a distal femoral traction pin, avoids unacceptable shortening and frontal plane malalignment in pediatric femoral fractures, which even have a relatively high risk of unacceptable shortening based on the so-called telescope test. However, the technique cannot avoid sagittal malalignment. Level of Evidence: Level 3

Evaluation of Reduction Accuracy of Suture-Button and Screw Fixation Techniques for Syndesmotic Injuries

Background: Among the most important predictors of functional results of treatment of syndesmotic injuries is the accurate restoration of the syndesmotic space. The purpose of this study was to investigate the reduction performance of screw fixation and suture-button techniques using images obtained from computed tomography (CT) scans. Methods: Patients at or below 65 years who were treated with screw or suture-button fixation for syndesmotic injuries accompanying ankle fractures between January 2012 and March 2015 were retrospectively reviewed in our regional trauma unit. A total of 52 patients were included in the present study. Fixation was performed with syndesmotic screws in 26 patients and suture-button fixation in 26 patients. The patients were divided into 2 groups according to the fixation methods. Postoperative CT scans were used for radiologic evaluation. Four parameters (anteroposterior reduction, rotational reduction, the cross-sectional syndesmotic area, and the distal tibiofibular volumes) were taken into consideration for the radiologic assessment. Functional evaluation of patients was done using the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale at the final follow-up. The mean follow-up period was 16.7 ± 11.0 months, and the mean age was 44.1 ± 13.2. Results: There was a statistically significant decrease in the degree of fibular rotation (P = .03) and an increase in the upper syndesmotic area (P = .006) compared with the contralateral limb in the screw fixation group. In the suture-button fixation group, there was a statistically significant increase in the lower syndesmotic area (P = .02) and distal tibiofibular volumes (P = .04) compared with the contralateral limbs. The mean AOFAS scores were 88.4 ± 9.2 and 86.1 ± 14.0 in the suture-button fixation and screw fixation group, respectively. There was no statistically significant difference in the functional ankle joint scores between the groups. Conclusion: Although the functional outcomes were similar, the restoration of the fibular rotation in the treatment of syndesmotic injuries by screw fixation was troublesome and the volume of the distal tibiofibular space increased with the suture-button fixation technique. Level of Evidence: Level III, retrospective comparative study.

Arthroscopic Treatment of a Case with Concomitant Subacromial and Subdeltoid Synovial Chondromatosis and Labrum Tear

Synovial chondromatosis is a disease that seldomly seen in shoulder joint and is related to benign synovial proliferation and synchronous chondral tissue formation within the joint cavity. Patients suffer from progressive restriction of range of motion and shoulder pain. Extra-articular involvement is an extremely rare condition. Degenerative osteoarthritis, joint subluxation, and bursitis are common complications in untreated patients. Open or arthroscopic surgery is suitable while there is no consensus related to superiority of different approaches. We presented an arthroscopic treatment of a male patient, 48 years old with labrum tear and synovial chondromatosis localized in subacromial and subdeltoid region. Advantages of arthroscopic surgery in the presence of intra- and extra-articular combined pathologies are also discussed.

The patellofemoral kinematics in patients with untreated developmental dislocation of the hip suffering from patellofemoral pain

PurposeThis study reviews the dynamic patellofemoral CT results of 39 patients with untreated developmental dislocation of the hip who are suffering from knee pain.MethodThe mean age of the patients with unilateral developmental dislocation of the hip was 33.3 (±7.9), for bilateral patients 36.2 (±11.3), and for the control group, it was 31.5 (±8.5). While 14 of them were bilateral, 25 were unilateral. The CT results of 24 asymptomatic adult knees served as the control group. The patellofemoral parameters of patients with unilateral and bilateral developmental dislocation of the hip, the control group’s parameters and the effect of femoral anteversion, limb length discrepancy, severity of dislocation, the mechanical axis deviation on patellofemoral parameters were analyzed.ResultsIn patients with unilateral untreated developmental dislocation of the hip, although the patella was located more laterally at initial flexion degrees, it was located more medially at 30° and 60° flexion with respect to the control group. For the involved extremity, the PTA angles at 15°, 30°, and 60° flexion were significantly higher than in the control group corresponding to medial patellar tilt. In patients with bilateral developmental dislocation of the hip, the course of the patella during tracking in terms of patellar shift was similar to that of the unilateral patients. The amount of leg length discrepancy and the severity of dislocation, as well as the mechanical axis deviation, did not affect the patellofemoral parameters.ConclusionThe patients with untreated developmental dislocation of the hip and suffering from knee pain should be analyzed not only for tibiofemoral abnormalities but also for patellofemoral malalignment.Level of evidenceCase–control study, Level III.

Acetabular components with or without screws in total hip arthroplasty

AIM To compare the operation time, blood loss, and early outcomes of acetabular components with and without the screw. METHODS Thirty patients who underwent cementless acetabular component with or without screw and whose follow-up exceeded one year period in total hip arthroplasty were evaluated. A posterior approach was used in all surgical procedures by one experienced surgeon. Demographic data, operation time, intra- and postoperative blood loss volume, follow-up clinical score, cup migration, and osteolysis were recorded. The Kolmogorov-Smirnov test was performed for testing the normality of study data. Mann-Whitney U test was used to analyze the inter-group differences. A P-value of ≤ 0.05 was considered statistically significant. RESULTS Acetabular components were used in 16 (53.3%) patients with screw and 14 (46.7%) without screw. After one year of follow-up, an osteolytic lesion of 3 mm was found in only one patient in the screw group. No cup migration was encountered. Intra-group mean Harris hip score significantly increased, but there was no significant inter-group difference. While the mean operation time of the screw group was 121.8 min (range; 95-140), it was 102.7 min (range; 80-120) in the no-screw group, and this difference was statistically significant (P = 0.002). The mean intraoperative/postoperative, and total blood loss were 556.6 mL (range: 350-800)/423.3 mL (range: 250-600), and 983.3 mL (range: 600-1350), respectively in the screw group; and 527 mL (range: 400-700)/456 mL (range: 230-600), and 983 mL (range: 630-1250), respectively in the no-screw group. The blood loss difference between the two groups was not significant. In the screw group, the operation time was 19.1 min longer than the no-screw group, and this difference was statistically significant. CONCLUSION Acetabular components with or without screw have similar results, but the use of screw increases the operation time significantly, while not changing the blood loss volume.

Gartland Type 3 Supracondylar Humeral Fractures in Children: Which Open Reduction Approach Should Be Used After Failed Closed Reduction?

Objectives: For displaced supracondylar humeral fractures in children, in the event of closed reduction failure, anatomic reduction is achieved via open reduction techniques; however, there are no confirmative reports among the published open reduction approaches that deliver the best functional and cosmetic results. Here, we compared long-term functional and cosmetic results of different surgical approaches. Design: Retrospective cohort study. Setting: Ankara Education and Research Hospital/Turkey. Secondary care hospital and trauma center. Patients/participants: We evaluated 70 surgically treated Gartland type 3 supracondylar humeral fractures. Patients, with detailed history record, were divided into 5 groups with respect to surgery methods. Intervention: All patients were treated surgically using closed reduction and percutaneous pinning or 4 different open reduction approaches and percutaneous pinning. Main Outcome Measures: Flynn cosmetic and functional score results were compared between surgical groups. Results: Posterior open reduction and triceps transection groups showed worst results, whereas medial and lateral open reduction groups showed good to excellent results similar to closed reduction group. Conclusion: Medial and lateral approaches demonstrated better functional results than posterior and triceps transection approaches. Posterior approaches lead to restrictions in extension and poor functional results. In the posterior approach, transecting triceps from olecranon does not benefit from fracture reduction but results in loss of triceps strength and should be avoided. In failed closed reduction, medial and lateral open reduction approaches lead to similar cosmetic outcomes and functional results that are only slightly worse compared with those in closed reduction. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Radiographic Dye Method for Intraoperative Evaluation of Syndesmotic Injuries

Background: The Chertsey test has been recently defined as an intraoperative test for the detection of the syndesmotic injuries by the application of intra-articular contrast. However, no study has investigated the reliability and comparative analysis of the Chertsey test. The purpose of this study was to explore the diagnostic accuracy of the Chertsey test in predicting syndesmosis instability of the injured ankle, with correlation to preoperative computed tomography (CT) findings. Methods: A total of 39 patients who were operated on due to the unilateral ankle fracture and had no complaint on the contralateral ankle joint were included in the study. An intraoperative Chertsey test was performed on all ankle fractures and bilateral ankle CT was obtained preoperatively. Ankles were classified as Chertsey +, Chertsey –, and contralateral control group. The morphology categorization, width, and volume of the syndesmotic region were measured on axial images of the CT. Mann-Whitney U test was used to compare the data. Intraobserver and interobserver agreements were accessed by calculating the intraclass correlation coefficient (ICC) for radiologic parameters and the Chertsey test. Results: The Chertsey test was positive in 13 (33.3%) of 39 ankle fractures. Patients with a positive Chertsey test showed a significant increase in syndesmotic width and volume compared with Chertsey – and control group. However, there was no significant difference between Chertsey – and the control group. All the ICC values were excellent for both radiologic measurements and test. Conclusion: The Chertsey test is a reliable and useful test that can be used intraoperatively in the diagnosis of syndesmotic injuries. Level of Evidence: III, comparative series.

The Role of Surgical Closure Position in Total Knee Arthroplasty: Flexion versus Extension—A Randomized Prospective Study

We aimed to investigate the effect of the knee position during the surgical closure on isokinetic muscle strength, clinical score, and range of motion in total knee arthroplasty. Seventy-five eligible patients were enrolled in the study and randomly divided into two groups; wound closure was performed with the knee flexed at 90° in group 1 and knee extended in group 2. All the surgeries were performed by the same surgeon and by the same prosthesis type. All the patients received the same rehabilitation program postoperatively. The primary outcomes were the knee flexion degrees and the American Knee Society Score values at preoperative and postoperative 6 weeks, 3, and 6 months. The secondary outcome was the isokinetic muscle strength measurements of both knees before the surgery and after 6 months. There were no significant differences in the American Knee Society Scores and knee flexion degrees between the flexion and extension groups. However, a significant decrease was found in the extensor muscle strength in the extension group after 6 months of the surgery. The findings of our study are that the closing of the knee in flexion or extension does not affect the postoperative knee flexion degrees and scores in total knee arthroplasty. However, quadriceps strength recovers early if the knee closure is performed in flexion position.

Subacromial space volume in patients with rotator cuff tear: The effect of surgical repair

Objective The aim of this study was to evaluate the effect of the rotator cuff tear repair on subacromial space volume. Methods We retrospectively identified 21 eligible patients (5 males and 16 females; mean age: 56.4 (range; 46–71) years) who had shoulder arthroscopy for unilateral full-thickness small to medium rotator cuff tear and normal controlateral shoulder joint. The mean follow-up time was 16.1 (range; 12–25) months. Preoperative and postoperative 1 year bilateral shoulder MRIs and Constant scores were reviewed. Subacromial volume was calculated by using Osirix software. Pre-, postoperative and healthy side (contralateral control group) subacromial volumes were recorded. Paired sample and t-tests were used to compare the pre- and postoperative groups. Independent sample t-tests were used to compare the healthy and pre- and postoperative groups. The correlation between the changes in the subacromial volume and the shoulder Constant score were analyzed using Pearson correlation analyses. Results The mean subacromial volume of the preoperative group was 2.95 cm3 (range; 1.53–4.23) and the postoperative group was 3.59 cm3 (range; 2.12–4.84). The volume increase was statistically significant (p < 0.05). The mean subacromial volume of the control group was 3.93 cm3 (range; 2.77–5.03), and the difference between the preoperative group and the control group was statistically significant. There was no significant difference found between the postoperative group and the control group (p = 0.156). There was no significant correlation found between the volume and the constant score changes (r = 0.170, p = 0.515). Conclusion The subacromial space volume significantly decreases in full-thickness rotator cuff tears smaller than 3 cm and the surgical repair increases the subacromial volume significantly. Level of evidence Level IV; Diagnostic Study.

PEDİATRİK ÖNKOL KIRIKLARININ İNTRAMEDÜLLER ELASTİK ÇİVİ İLE TEDAVİSİ

Amac: Onkol kiriklari, sik gorulen pediatrik yaralanmalardandir. Bu kiriklarin tedavisinde, acisal ve rotasyonel olarak uygun dizilim saglanarak kaynamanin elde edilmesi amaclanmaktadir. Bu calismada pediatrik onkol kirigi nedeniyle intrameduller elastik civileme (IEC) teknigi uygulanmis hastalarin geriye yonelik degerlendirilmesi amaclanmistir. Gerec ve Yontem: Pediatrik donem onkol kirigi nedeniyle Eylul 2013 – Aralik 2015 tarihleri arasinda IEC teknigi uygulanmis, en az alti ay takipli 33 hasta (27 erkek, 6 kiz; 15 sag, 18 sol taraf) geriye yonelik degerlendirildi. Hastalara ait demografik veriler, gelisen major komplikasyonlar ile radial egim indeksi ve lokasyonu degerlendirildi. Bulgular: Ortalama takip suresi 19.1 ± 8.8 ay, ortalama yas 10.6 ± 3.5 yil idi. Bir olguda reduksiyon kaybi, 1 olguda refraktur ve 1 olguda kaynama gecikmesi olmak uzere toplam 3 olguda (%9) major komplikasyon gelisti. Geriye kalan tum olgularda tam pronasyon ve supinasyon ile kaynama elde edildi. Ortalama radial egim noktasi, radius uzunlugunun %63.8 ± 5.4’ unde lokalize idi. Ortalama radial egim indeksi ise %5.5 ± 1.2 idi. Tum olgularda radial egim indeksi normal sinirlar icerisinde idi. Sonuc: Pediatrik donem onkol kiriklarinin tedavisinde IEC teknigi, yuksek kaynama orani ve kabul edilebilir komplikasyon orani ile uygun bir tedavi yontemidir. Anahtar kelimeler: Kanal ici civi, onkol kiriklari, cocuk, kirik, tespit