Dogan Bek

Pronation versus supination maneuvers for the reduction of 'pulled elbow': a randomized clinical trial.

Objectives The purpose of this study was to compare the efficiency of the hyperpronation and supination–flexion maneuvers in the reduction of the pulled elbow. Methods Sixty-six patients with pulled elbow were randomized for reduction with either hyperpronation or supination–flexion maneuvers. When the first attempt failed, a second attempt was performed with the same reduction maneuver. After failure of the second attempt the reduction maneuver was changed to the alternate method. The success rate of the reductions and the subjective rating on the difficulty of the reduction by the physician were recorded and analyzed statistically. Results Thirty-two of 34 patients (94%) in the hyperpronation group and 22 of 32 patients (69%) in the supination–flexion group were reduced at first attempt (P=0.007). Two patients in the hyperpronation group and seven patients in the supination–flexion group were reduced at the second attempt. Reduction rates were statistically similar (P=0.06). Three patients in the supination–flexion group had failed reduction at the second attempt and the reduction maneuver needed to be changed. They were successfully reduced with hyperpronation maneuver at the first attempt. Final success rate of the hyperpronation maneuver at the first attempt was statistically higher than the supination–flexion maneuver (P=0.004). Furthermore, the hyperpronation maneuver was rated significantly easier than the supination–flexion maneuver by physicians (P=0.003). Conclusion Although final reduction rates were similar, the hyperpronation maneuver was more efficient at the first attempt, easier for physicians and less painful for the children.

The relation between the arthroscopic findings and functional outcomes in patients with septic arthritis of the knee joint, treated with arthroscopic debridement and irrigation

OBJECTIVES The aim of this study was to evaluate the relation between arthroscopic findings and functional outcomes in patients with septic arthritis of the knee joint, treated with arthroscopic debridement and irrigation. METHODS Twenty patients (17 male, 3 female; mean age: 31 years [5-63 years]) with knee septic arthritis treated with arthroscopic debridement and irrigation in our clinic between 2004-2007 were included in the study. The decision for arthroscopic debridement was made based on the clinical findings, erythrocyte sedimentation rate, C-reactive protein level and the aspiration of the affected knee. During the arthroscopic debridement, the joint was staged according to Gachter criteria. Continuous irrigation system was set up for all cases following surgery. After the surgery, the Bussiere functional scale was used for clinical evaluation. The mean follow-up periodwas 29±11months (range 13-54 months). The McNemar test was used in comparing the results. The Spearman correlation coefficient was used in the correlation analysis. The level of significance was set at 0.05. RESULTS The culture was positive in 3 cases, and negative in 8 cases who exhibited gram (+) cocci in gram stains. In nine cases, cultures were negative and no microorganisms were detected in gram stains. According to the arthroscopic Gachter classification, 4 cases (20%) were Stage 1, 10 cases (50%) were Stage 2, 5 cases (25%) Stage 3 and 1 case (5%) was Stage 4. There was a statistically significant difference between the mean functional score of the knees with differing Gachter stages (McNemar test, p=0.003). There was a statistically significant and strong correlation between Gachter score and functional results (correlation coefficient: 0.780; p<0.001). CONCLUSION Advanced arthroscopic findings are associated with poor functional results in patients with septic arthritis of the knee joint. In addition, the time between the initial symptoms and the surgery directly affects the functional results.

Neglected patellar tendon rupture: a case of reconstruction without quadriceps lengthening

Neglected rupture of the patellar tendon is a rare, can be easily missed in a group of patients. We present a 24 year old, male patient who sustained right femoral diaphyseal and tibial plateau fractures and a patellar tendon rupture following a motor vehicle accident. The fractures were treated by open reduction internal fixation but the patellar tendon rupture was missed and the diagnosis was delayed by 7 months. Patella was migrated proximally. It was moved distally to the original location and neglected patellar tendon rupture treated successfully with modified Ecker technique. Neither preoperative traction nor additional intraoperative procedures were performed to relocate the patella to its anatomic position in the extended knee and good functional result was achieved with intensive rehabilitation.

Removal of a bent inflatable femoral nail: a case report

Intramedullary nailing is the gold standard for the treatment of diaphyseal femoral fractures. Bending of the nail secondary to trauma is a rare complication encountered in unhealed and comminuted fractures. A 23-year-old man was admitted with refracture of the right femoral shaft and a 32-degree bending of an inflatable intramedullary nail due to a fall, two months after the initial surgical treatment. The nail was first straightened by exerting an external force, which decreased the angulation to 10 degrees. Then, the fracture site was opened, the lateral wall of the nail was drilled, and one of the four metal bars of the nail was cut. This allowed complete straightening of the nail by the same maneuver and its removal. A new inflatable intramedullary nail was placed and union was achieved after four months. Tools that may be necessary to cut the nail partially or totally should be made available for removal of bent nails.

Turkish Version of Kolcaba's Immobilization Comfort Questionnaire: A Validity and Reliability Study

PURPOSE The purpose of this study was to determine the validity and reliability of the Turkish version of the Immobilization Comfort Questionnaire (ICQ). METHODS The sample used in this methodological study consisted of 121 patients undergoing lower extremity arthroscopy in a training and research hospital. The validity study of the questionnaire assessed language validity, structural validity and criterion validity. Structural validity was evaluated via exploratory factor analysis. Criterion validity was evaluated by assessing the correlation between the visual analog scale (VAS) scores (i.e., the comfort and pain VAS scores) and the ICQ scores using Spearmans correlation test. The Kaiser-Meyer-Olkin coefficient and Bartletts test of sphericity were used to determine the suitability of the data for factor analysis. Internal consistency was evaluated to determine reliability. The data were analyzed with SPSS version 15.00 for Windows. Descriptive statistics were presented as frequencies, percentages, means and standard deviations. A p value ≤ .05 was considered statistically significant. RESULTS A moderate positive correlation was found between the ICQ scores and the VAS comfort scores; a moderate negative correlation was found between the ICQ and the VAS pain measures in the criterion validity analysis. Cronbach α values of .75 and .82 were found for the first and second measurements, respectively. CONCLUSIONS The findings of this study reveal that the ICQ is a valid and reliable tool for assessing the comfort of patients in Turkey who are immobilized because of lower extremity orthopedic problems.

Prediction of the Presence of Plantaris Tendon Through Examination of Palmaris Longus Tendon: Is There a Link?

El proposito de este estudio fue investigar la relacion entre los tendones del musculo palmar largo (MPL ) y musculo plantar (MP) y poner a prueba la utilidad clinica de los patrones de simetria entre estos tendones de la poblacion turca. Estudio prospectivo realizado sobre 240 pacientes adultos (120 hombres y 120 mujeres) que ingresaron en la clinica por sintomas de dolor en la rodilla bilateralmente, quienes requerian un examen de RM de rodilla durante dos anos. Se utilizo la prueba estandar (prueba de Schaefer, se oponen el pulgar hasta el dedo minimo, mientras se flexiona la muneca) para evaluar la presencia del tendon MPL tanto con la inspeccion y palpacion. La RM de la rodilla se utilizo para determinar la presencia de vientre muscular plantar en ambos lados. Se analizo el patron de distribucion simetrica mediante la prueba de McNemar. El tendon del MPL estuvo ausente de manera unilateral en 34 pacientes (14,2%) y bilateralmente en 17 pacientes (7,1%). El tendon del MP estuvo ausente de manera unilateral en 51 pacientes ( 21,3 %) mientras que bilateralmente no estaba en 10 pacientes (4,2%). Si el tendon del MPL estuvo ausente en un lado, la probabilidad de tener un tendon del MP ipsilateral fue del 70,6 %. Si el tendon del MPL estaba presente en un lado, la probabilidad de tener un tendon del MP ipsilateral fue 87,6%. La prueba de McNemar - simetria produjo un valor p de 0,841 para los musculos PL y P ipsilaterales. Una relacion directa claro entre los tendones de los musculos PL y P no se pudo demostrar en este estudio. Ambos musculos muestran diferentes variaciones independiente uno del otro.

Femoral neck fractures in hemodialysis patients: from the perspective of the orthopedic surgeon.

To the editor, A 60-year-old female with end stage renal failure and receiving hemodialysis for the last five years was seen for progressively increasing right hip pain over seven days. Although the pain existed only during walking before, she declared that she suffered from persistent pain and coxalgic gait during the last two days. Physical examination revealed painful right hip motions. Radiological evaluations were consistent with right displaced femoral neck fracture (see Figure 1). Bone mineral density measurements were relevant with osteoporosis. As the fracture was considered to have ensued more than seven days ago, an open reduction and internal fixation was not performed. Instead, bipolar hip arthroplasty was carried out, and she was mobilized with a walker on the second day of surgery. It is known that patients with end stage renal disease have reduced bone mineral density and thus are prone to femoral neck fractures. Other than the metabolic bone disease, specific factors such as amyloidosis, hypogonadism, avascular necrosis, and chronic acidosis may play role in the pathogenesis of reduced bone mass in these patients. General risk factors for the population (e.g., immobility, protein wasting, low body mass, and diabetes) also have imposed a greater burden on these patients. The reason we have reported our patient was the fact that in femoral neck fractures, early radiological evaluation and prompt diagnosis before the hip joint is displaced is quite important. In such cases, open reduction and internal fixation can be applied; however, in late cases (i.e., after 12 hours of fracture), the vascular supply of the femoral head is impaired, and the patient is left with the

Ankle Arthrodesis Using an Ilizarov External Fixator in Patients Wounded by Landmines and Gunshots

Background: We evaluated the results of ankle arthrodesis performed with circular external fixators (CEF) in those patients who had developed tibiotalar arthritis secondary to a landmine or a gunshot injury. Materials and Methods: Nineteen ankles in 19 patients were fused using CEF. All patients had approximately 3 (range, 1 to 5) operations for bone and soft tissue reconstruction preceding the arthrodesis. Ankle arthrodesis was performed an average of 2.3 (range, 1 to 7) years after the initial trauma. The mean age at operation was 22 (range, 20 to 31) years old and all patients were male. Results: The average time spent in the CEF was 3.5 (range, 2 to 7) months. The mean followup was 59 (range, 31 to 90) months. Successful arthrodesis was achieved in all patients in an acceptable position. Clinically, 6 patients were assessed as excellent, 9 patients as good, 3 patients as fair, and 1 patient had a poor result. Twelve patients reported no pain postoperatively, 4 patients reported reduced to mild and/or occasional pain, 2 patients reported moderate pain, and 1 patient reported persistent pain. Sixteen patients described their outcome as satisfactory, one was somewhat satisfied, and two were dissatisfied. There were pin track infections in 10 patients and ring sequestration in one patient. Conclusion: Patients who have degenerative ankle arthritis due to gunshot wounds and landmine injuries with poor bone quality and soft tissue conditions at the distal tibia can be successfully managed by using CEF.

Reliability of the mangled extremity severity score in combat-related upper and lower extremity injuries.

Background: Decision of limb salvage or amputation is generally aided with several trauma scoring systems such as the mangled extremity severity score (MESS). However, the reliability of the injury scores in the settling of open fractures due to explosives and missiles is challenging. Mortality and morbidity of the extremity trauma due to firearms are generally associated with time delay in revascularization, injury mechanism, anatomy of the injured site, associated injuries, age and the environmental circumstance. The purpose of the retrospective study was to evaluate the extent of extremity injuries due to ballistic missiles and to detect the reliability of mangled extremity severity score (MESS) in both upper and lower extremities. Materials and Methods: Between 2004 and 2014, 139 Gustillo Anderson Type III open fractures of both the upper and lower extremities were enrolled in the study. Data for patient age, fire arm type, transporting time from the field to the hospital (and the method), injury severity scores, MESS scores, fracture types, amputation levels, bone fixation methods and postoperative infections and complications retrieved from the two level-2 trauma centers data base. Sensitivity, specificity, positive and negative predictive values of the MESS were calculated to detect the ability in deciding amputation in the mangled limb. Results: Amputation was performed in 39 extremities and limb salvage attempted in 100 extremities. The mean followup time was 14.6 months (range 6–32 months). In the amputated group, the mean MESS scores for upper and lower extremity were 8.8 (range 6–11) and 9.24 (range 6–11), respectively. In the limb salvage group, the mean MESS scores for upper and lower extremities were 5.29 (range 4–7) and 5.19 (range 3–8), respectively. Sensitivity of MESS in upper and lower extremities were calculated as 80% and 79.4% and positive predictive values detected as 55.55% and 83.3%, respectively. Specificity of MESS score for upper and lower extremities was 84% and 86.6%; negative predictive values were calculated as 95.45% and 90.2%, respectively. Conclusion: MESS is not predictive in combat related extremity injuries especially if between a score of 6–8. Limb ischemia and presence or absence of shock can be used in initial decision-making for amputation.

An uncommon presentation of malignant fibrous histiocytoma of the calcaneus.

Malignant fibrous histiocytoma of bone is the osseous counterpart of the tumor in soft tissue. It is a rare primary bone tumor, and there have been conflicting reports on its grades of malignancy. The appendicular skeleton, especially the femur, is the most common site of involvement, whereas the calcaneus is rarely involved. We describe a primary malignant fibrous histiocytoma of the calcaneal bone in a 21-year-old man. The patient underwent neoadjuvant and adjuvant chemotherapy and below-the-knee amputation, and no local recurrence or metastasis was noted after 2 years of follow-up.