Fuat Bilgili

Ponseti technique for the correction of idiopathic clubfeet presenting up to 1 year of age. A preliminary study in children with untreated or complex deformities.

Introduction: The aim of this study is to evaluate the effectiveness of the Ponseti method in children presenting before 1 year of age with either untreated or complex (initially treated unsuccessfully by other conservative methods) idiopathic clubfeet. Patients and methods: The authors report 134 feet of 92 patients with Dimeglio grade 2, 3, or 4 deformities treated with the Ponseti method. Twenty-four percent of feet were of complex deformities at initial presentation to the authors’ clinics. Results: At a mean follow-up of 46 months (range 24–89) we avoided joint release surgery in 97% of feet. Sixty-seven percent required a percutaneous tenotomy of the Achilles tendon. Relapse rate was 31% (41 feet). We treated 2 relapses by restarting the use of orthosis, 17 with re-casting, 18 with anterior tibial tendon transfer following a second relapse, and 4 feet with extensive joint surgery. Compliance with the use of orthosis was identified as the most important risk factor (P<0.0001) for relapses. Previous unsuccessful treatment attempts by other conservative methods did not adversely affect the results unless the cases had iatrogenic deformities. Cases with iatrogenic deformities from previous treatment had a significantly increased risk of non-compliance and relapse. Experience of the treating surgeon and cast complications were also related to relapses. Conclusion: Our results show that the Ponseti technique is reproducible and effective in children at least up to 12 months of age. It can also produce good correction in children presenting with complex idiopathic deformities. Therefore, extensive joint releases should not be considered immediately in such cases. The treating surgeon should be meticulous in using the technique and ensure compliance to foot abduction brace in order to avoid recurrences.

Anatomic Course of the Superficial Branch of the Radial Nerve in the Wrist and Its Location in Relation to Wrist Arthroscopy Portals: A Cadaveric Study

PURPOSE The aim of this study was to assess the course of the superficial branch of the radial nerve (SBRN) at the level of the wrist and its branches in relation to wrist arthroscopy portals. METHODS Dissections were performed on 11 hands from 6 cadavers in the section starting from the point where the SBRN begins to emerge and ending at the terminal branches of the dorsal hand. The distribution of the SBRN, the distance from the superficial branch to the dorsal portals used in wrist arthroscopy, and the distance from the superficial branch to the anatomic determinants (styloid process of the radius, Lister tubercle) were studied. RESULTS At the level of the wrist, the nerve bifurcated into 2 branches in 8 of 11 wrists (73%) and into 3 branches in 3 of 11 wrists (27%). The mean distance from the SBRN where it was first detected proximal to the Lister tubercle was 73 mm. The mean distance between the styloids was 52 mm; the distance between the Lister tubercle and styloid process of the radius was 23 mm. At the wrist level, the distance from the branch closest to the radial side to the Lister tubercle was 28 mm (L-D1), 21 mm (L-D2/3), and 7 mm (RS-D1). The distance of the closest nerve branch to the 3-4 portal was 9 mm. The distances of the other portals were 5 mm (1-2RMC-D1), 8 mm (1-2RMC-D2/3), 8 mm (1-2P-D1), and 9 mm (1-2P-D2/3). CONCLUSIONS The limited size of the area where portals can be positioned and the anatomic variations between individuals are major obstacles in developing a guideline for reducing the risk of SBRN injury in wrist arthroscopy. CLINICAL RELEVANCE Great care must be taken when using the 1-2 portal. We suggest making a skin-only incision for this portal and then using blunt dissection to help prevent injury to the SBRN.

Short-term results of the Oxford phase 3 unicompartmental knee arthroplasty for medial arthritis

OBJECTIVES We evaluated short-term results of the Oxford phase 3 unicompartmental knee arthroplasty (UKA) in patients with medial compartment arthritis. METHODS The study included 38 patients (28 females, 10 males; mean age 67 years; range 56 to 75 years) who underwent UKA for isolated medial knee osteoarthritis. At the time of surgery, 28 patients were in the age group of 56-64 years, and 10 patients were in the age group of 65-75 years. All the patients had Ahlbäck grade 2 primary medial compartment arthritis that had been unresponsive to conservative treatment. None of the patients had symptoms of patellofemoral arthrosis. Patients underwent UKA with the Oxford phase 3 cemented meniscal-bearing unicondylar prosthesis using minimally invasive surgery. The results were assessed preoperatively and at final controls according to the Knee Society clinical and functional rating system. Postoperative radiographic evaluations were made according to the Oxford criteria. The mean follow-up period was 24 months (range 18 to 32 months). RESULTS The mean preoperative active knee flexion increased from 121.8 degrees (range 110 degrees to 130 degrees ) to 130.9 degrees (range 120 degrees to 140 degrees) postoperatively (p<0.05). There was no limitation in knee extension both pre- and postoperatively. The mean preoperative and postoperative knee scores were 64.6 (range 47 to 80) and 97.5 (range 89 to 100), and the mean functional scores were 59.6 (range 45 to 80) and 92.1 (range 70 to 100), respectively (p<0.05). All the patients had an excellent knee score, while functional scores were excellent in 27 patients (71.1%) and good in 11 patients (28.9%). Postoperative radiographic measurements showed that the position of the femoral components was within acceptable ranges in all the patients with a mean of 3 degrees valgus (range 5 degrees valgus to 8 degrees varus) and 0.5 degrees extension (range 3 degrees extension to 2 degrees flexion). The positioning of the femoral components in relation to the mechanical axis was central in 30 patients and 2-mm lateral (range 2 mm medial to 4 mm lateral) in eight patients. The position of the tibial components was also within acceptable ranges in all the patients with a mean of 1.5 degrees varus (range 2 degrees varus to 2 degrees valgus) and a mean posterior inclination of 6.2 degrees (range 5 degrees to 7 degrees). All the tibial components showed full congruency with the medial, lateral, anterior, and posterior planes, except for one which had a 4-mm undersizing in the anterior plane. The polyethylene insert was central and parallel to the tibial component in all the patients. No osteophytes or cement debris that might lead to impingement were observed. All the components remained in position until the final controls. Complications such as insert dislocation, infection, pulmonary embolism, deep venous thrombosis, or neurovascular injury were not observed. None of the patients required revision surgery. CONCLUSION Our findings show that, with proper patient selection and strict adherence to the surgical technique, short-term results of the Oxford phase 3 unicompartmental knee prosthesis are excellent or good in the treatment of medial compartment osteoarthritis.

Extramembranous transfer of the tibialis posterior tendon for the correction of drop foot deformity

OBJECTIVES We evaluated the effectiveness of extramembranous transfer of the tibialis posterior (TP) tendon for the treatment of drop foot deformity. METHODS The study included 13 patients (6 females, 7 males; mean age 30 years; range 10 to 46 years) who underwent 15 tendon transfers for drop foot deformity. Ten patients (76.9%) had deformity due to unrepairable nerve injuries, which were associated with surgical procedures in six patients and trauma in the remaining four. In four feet (26.7%), the TP tendon was turned from the intero-anterior aspect of the tibia and fixed by tenodesis to the lateral cuneiform bone, while in 11 feet (73.4%), it was transferred to the extensor hallucis longus, extensor digitorum communis, and peroneus tertius tendons. The patients were assessed according to the Stanmore system questionnaire. The mean follow-up was 25.3 months (range 12 to 80 months). RESULTS According to the Stanmore system, the results were poor in two feet (13.3%), moderate in three feet (20%), good in three feet, and very good in seven feet (46.7%). All the patients were satisfied with the final outcome. The mean foot dorsiflexion was 5 degrees (range, -5 degrees to 10 degrees ), which was 10 degrees in four feet (26.7%), and 5 degrees to 10 degrees in six feet (40%). Apart from complaints of bulging in four patients (30.8%) in the dorsum of the foot due to tendon and suture material, no complications were seen during the early postoperative period. CONCLUSION Extramembranous transfer of the TP tendon for the treatment of drop foot deformity enables the patients to walk without the aid of orthosis and increases their quality of life.

Arthroscopic excision of acetabular osteoid osteoma in a 7-year-old patient.

The purpose of this study was to present the case report of a 7-year-old patient who was treated with hip arthroscopy for an acetabular osteoid osteoma. A 7-year-old patient was referred to our clinic with hip pain. In the assessment of the patient, an acetabular osteoid osteoma was detected in his right hip; it was adjacent to his triradiate cartilage. An arthroscopic surgery was planned as an alternative to open safe hip dislocation. The osteoid osteoma was completely removed with hip arthroscopy. Postoperative CT scanning and histopathological analysis confirmed the diagnosis. Exposure of the acetabulum can be problematic in paediatric patients due to the potential risks of open safe dislocation. Hip arthroscopy can safely be used for benign hip lesions in paediatric patients. Level of evidence Case report, Level V.

Can Normal Fracture Healing Be Achieved When the Implant Is Retained on the Basis of Infection? An Experimental Animal Model

BackgroundInfection after open fractures is a common complication. Treatment options for infections developed after intramedullary nailing surgery remain a topic of controversy. We therefore used a rat fracture model to evaluate the effects of infection on osseous union when the implant was maintained.Questions/purposesIn a rat model, (1) does infection alter callus strength; (2) does infection alter the radiographic appearance of callus; and (3) does infection alter the histological properties of callus?MethodsAn open femoral fracture was created and fixed with an intramedullary Kirschner wire in 72 adult male Sprague-Dawley rats, which were divided into two study groups. In the infection group, the fracture site was contaminated with Staphylococcus aureus (36 animals), whereas in the control group, there was no bacterial contamination (36 animals). No antibiotics were used either for prophylaxis or for treatment. We performed biomechanical (maximum torque causing failure and stiffness), radiographic (Lane and Sandhu scoring for callus formation), and histologic (scoring for callus maturity) assessments at 3 and 6 weeks. The number of bacteria colonies on the femur, wire, and soft tissue inside knee were compared to validate that we successfully created an infection model. The number of bacteria colonies in the soft tissue inside the knee was higher in the infection group after 6 weeks than after the third week, demonstrating the presence of locally aggressive infection.ResultsInfection decreased callus strength at 6 weeks. Torque to failure (299.07 ± 65.53 Nmm versus 107.20 ± 88.81, mean difference with 95% confidence interval, 192 [43–340]; p = 0.007) and stiffness at 6 weeks (11.28 ± 2.67 Nmm versus 2.03 ± 1.68, mean difference with 95% confidence interval, 9 [3–16]; p = 0.004) both were greater in the control group than in the group with infection. Radiographic analysis at 6 weeks demonstrated the fracture line was less distinct (Lane and Sandhu score of 2–3) in the infection group and complete union was observed (Lane and Sandhu score of 3–4) in the control group (p = 0.001). Semiquantitative histology scores were not different between the noninfected controls and the rats with infection (score 10 versus 9).ConclusionsRetaining an implant in the presence of an underlying infection without antibiotic treatment leads to weaker callus and impedes callus maturation compared with noninfected controls in a rat model. Future studies might evaluate whether antibiotic treatment would modify this result.Clinical RelevanceThis model sets the stage for further investigations that might study the influence of different interventions on fracture healing in implant-associated osteomyelitis. Future observational studies might also evaluate the histological properties of callus in patients with osteomyelitis.

The effects of preoperative non-invasive cardiac tests on delay to surgery and subsequent mortality in elderly patients with hip fracture

OBJECTIVE To investigate the effects of preoperative cardiac tests on the surgical treatment plan and subsequent effects on mortality in elderly patients with hip fracture. METHODS In this retrospective study, 116 patients aged 60 years or above who underwent hip fracture surgery between 2010-2013 were evaluated. Of the patients with similar preoperative clinical risk factors, 20 patients with additional preoperative cardiac tests such as echocardiography or thalium scintigraphy constituted Group 1, whereas 28 patients without additional cardiac tests constituted Group 2. Statistical analyses were performed using the SPSS 21 statistical package software. Normal distribution of the data was determined by the Shapiro-Wilk test and histography. Intergroup and mortality comparisons were performed by Mann-Whitney U, Yates-corrected chi-square and Fishers exact tests. RESULTS The mean time between fracture and operation was 6 days (range, 4-14) in Group 1, and 2 days (range, 0-3) in Group 2. There was a significant difference in time-to-operation between the groups (p< 0.001). The age and gender distribution of both groups were homomgenous (p= 0.64, p= 1.0). Both groups were comparable in terms of fracture type, treatment, and anesthesia (p= 0.36, p= 0.42, p= 1.0). At the end of 1 year, six (30%) patients in Group 1 and three (10.7%) patients in Group 2 were deceased. Both groups were comparable in terms of mortality (p= 0.137). There was a significant difference between the two groups in terms of complications (p< 0.05). CONCLUSIONS Unnecessary cardiac tests in elderly patients with hip fracture led to a delay in their surgery, yet did not change their cardiac treatment plan. This delay in obtaining hip fracture surgery increases complication rates, hospitalization duration, and costs.

Preliminary report on amputation versus reconstruction in treatment of tibial hemimelia

OBJECTIVE Tibial hemimelia is a rare disorder characterized by the absence or hypoplasia of the tibia with associated rigidity. The aim of this study was to retrospectively evaluate the affectivity of reconstructive surgeries including centralization of the knee-ankle joints and lengthening with Ilizarov principles, as well as physical and functional results of amputation and reconstruction. METHODS This is an IRB-approved retrospective review of all patients diagnosed with tibial hemimelia who required surgery at a single institution between 1998 and 2011. Charts were analyzed for clinical and radiographical findings. At final follow-up, patients underwent physical and radiographic examination. Patients and their parents were asked to complete the SF-10™ health survey (QualityMetric Inc., Lincoln, RI, USA). RESULTS Twenty-one patients (12 male, 9 female) with 30 affected extremities were included. Mean age was 4.8±3.1 years at initial surgery. Knee level disarticulation was performed in 6 extremities of 4 patients. One patient with type III underwent transtibial amputation. Mean number of surgeries for each patient was 6.4±3.3, and mean duration of external fixator and casting was 17±6 months. Mean lengthening was 4.9±1.3 cm, and mean limb length discrepancy was 3.1±1.7 cm at 5.8±3.7 years at follow-up. SF-10™ scores were similar in disarticulated and reconstructed patients (p=0.63). All scores were significantly higher when disarticulation was performed in cases of knee instability (p<0.01). CONCLUSION When stability of the knee joint is present, treatment modality should be chosen according to the existence of the proximal tibia. Amputation should be preferred in cases of knee joint instability.

An analysis of variables affecting the duration of Pavlik harness treatment: Is it possible to predict the duration of treatment?

Background: Pavlik harness is the initial treatment for the infants with developmental dysplasia of the hip who have not yet begun walking. Objectives: The present study evaluates the variables which affect the duration of PH treatment for patients successfully treated. Study design: Cross-sectional study. Methods: Pavlik harness was employed for 140 hips of 87 patients with developmental dysplasia of the hip in our institution between 2010 and 2013. In all, 55 hips of 46 patients who were treated successfully with Pavlik harness were included in this study. According to Graf’s sonographic classification, 23 hips were Type IIC, 26 were Type IID, and 6 were Type III. The studied variables were (1) alpha angle, (2) age at the start of treatment, (3) laterality, and (4) gender. The variables were compared with the duration of Pavlik harness treatment. Results: A highly significant inverse correlation was observed between Pavlik harness application time and alpha angle at the start of the treatment (r = –0.050; p < 0.001). Bilateral involvement has statistically longer duration, when compared with unilateral involvement (r = 0.28; p = 0.036). No statistically significant difference was present between duration of treatment and age at the start of Pavlik harness treatment (r = –0.034; p = 0.804). There was no statistical significance between gender and duration of Pavlik harness (r = 0.201; p > 0.05). Conclusion: The duration of treatment was negatively correlated with the initial alpha angle. A change of 1 degree in alpha angle may alter the duration of treatment as 0.89 week calculated by the formula (Application time (Week) = 56.6 – 0.89 × alpha angle). Bilateral involvement may need longer Pavlik harness treatment. Clinical relevance Pavlik harnes generally is the first treatment method for the infants with DDH. This study suggest conclutions about how long time is the Pavlik harness should be kept on the infants? The main indicator is initial alfa angle which is negatively correlated with the duration of treatment.

Treatment of Pediatric Fractures with Ilizarov’s Method

Pediatric long bones have some different characteristics including thicker periosteum, better blood supply, shorter healing time, and higher remodeling capacity than the adult bone. Therefore, most fractures are treated conservatively with traction or casting. However, the prolongation of the treatment can cause “casting disease,” which manifests as joint stiffness, muscle weakness, and disuse osteopenia [1]. Prolonged treatment also prevents parents from working and children from going to school. The cost of treatment with external fixation is lower than treatment with traction in hospital and hospital/home (Hedin 2004).