Hasan Hilmi Muratli

The results of nonoperative treatment for three- and four-part fractures of the proximal humerus in low-demand patients.

Objective: To evaluate the results of nonoperative treatment of three- and four-part fractures of the proximal humerus in patients who refused surgery or could not undergo surgery because of medical conditions. Design: Retrospective evaluation of prospective collected data. Setting: Educational and research hospital. Level IV, therapeutic case series. Patients: Eighteen patients (eight three- and 10 four-part fractures) were included. The mean age was 68.2 ± 13.8 years (range, 39–90 years). The mean follow-up was 39.1 ± 12.4 months (range, 24–60 months). Patients were grouped into two: Group A being younger than 65 years and Group B 65 years or older. Intervention: Standardized nonoperative treatment and follow-up protocols were used. Main Outcome Measurements: Functional and radiographic assessments were performed in posttreatment first year and at latest follow-up. Constant-Murley scores were also obtained for both shoulders. Results: The mean Constant-Murley score was 61.3 ± 13.5 (range, 40–85) at latest follow-up. Osteonecrosis was detected in five patients. All patients had significantly lower SF-36 scores for all subscales except mental health than the normal Turkish population. There was no significant difference between three- and four-part fractures regarding age and Constant-Murley scores. The mean Constant-Murley score of the Group A patients with three-part fractures was significantly higher when compared with the Group A patients with four-part fractures. There was no significant difference between patients with and without osteonecrosis regarding fracture types or the Constant-Murley scores at the latest follow-up. Conclusions: Although the individual fracture type does not have an influence on functional results, these results are better in patients younger than 65 years with three-part fractures. The results of the nonoperative treatment of these fractures are satisfactory even in elderly patients. The radiographic appearances did not correspond with the functional results.

Magnetic resonance arthrographic evaluation of syndesmotic diastasis in ankle fractures

IntroductionWe examined whether magnetic resonance arthrography (MRA) contributes to the diagnosis of syndesmotic complex disruption in ankle fractures. Patients suffering syndesmotic diastasis according to conventional radiographic criteria were evaluated by MRI and MRA.Material and methodsFifteen patients (15 ankles) with Denis-Weber type B and C fractures and were suspected of having syndesmotic diastasis considering tibiofibular clear space and tibiofibular overlap measurements in conventional radiographs were prospectively evaluated by MRI and MRA methods. Syndesmotic diastasis was diagnosed by radiographic, MRI, and MRA findings and by intraoperative observation and assessment criteria. Differences between MRI and MRA findings were tested statistically. Conventional radiography, MRI, and MRA results were analyzed by two independent observers, and interobserver concordance was also assessed.ResultsIn 15 patients regarded to have syndesmotic diastasis on conventional radiography the diagnosis was confirmed in 8 (53.3%) with MRI and 12 (80%) with MRA. Following overall assessment 13 of 15 patients (86.6%) were determined to have diastasis. There were statistically significant differences in diagnosis after MRI and after MRA. There was interobserver concordance in conventional radiographic, MRA assessments, and in assessments for anterior and posterior tibiofibular ligaments separately in MRI.ConclusionsThese results suggest that conventional radiography and MRI is not sufficient in assessing syndesmotic disruption, and that MRA can make an important contribution to diagnosis in ankle fractures.

Bilateral patellar tendon rupture in a child: a case report.

Patellar tendon rupture in children is very rare. When it occurs, patellar tendon is usually ruptured either from the upper end as a sleeve fracture of the patella or from lower end as an avulsion fracture of the tibial tuberosity. In this report, we present the case of an otherwise healthy 9-years-old boy who had subsequent bilateral patellar tendon ruptures through the midparts, which has not been published previously in the literature. Treatment was performed with primary end-to-end repair, reinforcement with cerclage wires and fresh-frozen achilles tendon augmentation for both sides.

Bensahel et al. and International Clubfoot Study Group evaluation of treated clubfoot: assessment of interobserver and intraobserver reliability.

In order to assess interobserver and intraobserver reliability of an evaluation system of the International Clubfoot Study Group, 30 children treated for unilateral clubfoot and their radiographs were examined by three different observers. The mean intraobserver κ value was found to be 0.62. The mean interobserver κ value was 0.73. These κ values correlated with a substantial degree of agreement. Interobserver reliability for all subgroup evaluations (morphologic, functional and radiological) and total scores was 90% or over. This also indicates a good interobserver reliability. In conclusion, the Bensahel et al. and International Clubfoot Study Group outcome evaluation system may be used reliably for the assessment of outcome of the treatment of clubfoot.

Gait characteristics of patients with bilateral club feet following posteromedial release procedure.

In this study we intended to evaluate the gait characteristics of children who had bilateral operated clubfeet, and to compare the results with gait parameters of children without clubfeet or lower extremity abnormalities. Fifteen children with bilateral plantigrade and asymptomatic clubfeet, operated bilaterally with posteromedial release method, were included in group P. Means±SD of age and follow-up time were 8.5±2.6 years (range, 4–14 years) and 7.7±2.8 years (range, 3–10 years), respectively. Age, sex, height-and weight-matched 24 children without clubfeet or lower extremity abnormalities were included in the control group (group C). Three-dimensional computerized gait analysis was performed for all subjects, and time–distance, kinematic and kinetic gait characteristics of the groups were compared. Time-distance characteristics of the groups were identical. Ankle plantar flexion angles, plantar flexor moment and generated power were significantly decreased in group P (P<0.05). Knee hyperextension during midstance was observed in 17 of 30 (57%) knees in the P group. Kinetic analysis revealed excessive knee valgus and flexion moments, as well as decreased second peak values of vertical ground reaction forces for group P. This study shows that even successfully operated, plantigrade and clinically asymptomatic children with bilateral clubfeet have significant gait deviations involving all lower limb joints. Future studies are needed to investigate the accountable factors of gait deviations and possible long-term musculoskeletal morbidity of operated children with bilateral clubfeet.

Comparison of plasma endothelin levels between osteoporotic, osteopenic and normal subjects

BackgroundIt has been demonstrated that endothelins (ET) have significant roles in bone remodeling, metabolism and physiopathology of several bone diseases. We aimed to investigate if there was any difference between the plasma ET levels of osteoporotic patients and normals.Methods86 patients (70 women and 16 men) with a mean age of 62.6 (ranges: 51–90) years were included in this study. Patients were divided into groups of osteoporosis, osteopenia and normal regarding reported T scores of DEXA evaluation according to the suggestions of World Health Organization. According to these criteria 19, 43 and 24 were normal, osteopenic and osteoporotic respectively. Then total plasma level of ET was measured in all patients with monoclonal antibody based sandwich immunoassay (EIA) method. One-way analysis of variance test was used to compare endothelin values between normals, osteopenics and osteoporotics.ResultsEndothelin total plasma level in patients was a mean of 98.36 ± 63.96, 100.92 ± 47.2 and 99.56 ± 56.6 pg/ml in osteoporotic, osteopenic and normal groups respectively. The difference between groups was not significant (p > 0.05).ConclusionNo significant differences in plasma ET levels among three groups of study participants could be detected in this study.

Mechanoreceptor evaluation of hip joint capsule and ligamentum capitis femoris in developmental hip dysplasia: a preliminary study.

We aimed to determine if there are mechanoreceptors in the hip joint capsule and ligamentum capitis femoris (LCF) of patients with developmental dysplasia of the hip (DDH). We took capsule and LCF biopsies from 20 hips of 20 patients who were operated on because of DDH. The mean age was 10.2 months (range 6–20 months) at the time of surgery. There were 12 girls and eight boys. Teratologic and secondary hip dislocations were not included in this study. Full thickness, 0.5×0.5 cm anterior capsule and LCF portions were taken for biopsy specimen. Specimens were stained with hemotoxylin eosin and examined immunohistochemically using monoclonal antibody against S-100 protein. In both analyses no mechanoreceptor was found in any samples of capsule or LCF. In this preliminary study we could not find mechanoreceptors in the local anterior joint capsule and LCF of the hip in children with DDH. We think that additional studies are necessary in order to understand the mechanoreceptor characteristics of the hip joint in children not only with DDH but also in children with healthy hips.

[Cementless total hip replacement in patients with high total dislocation: the results of femoral shortening by subtrochanteric segmental resection].

OBJECTIVES We evaluated the results of femoral shortening by subtrochanteric segmental resection in patients who underwent total hip replacement (THR) for high total dislocation of the hip. METHODS We performed THR in 19 hips of 16 patients (15 females, 1 male; mean age 41 years; range 22 to 55 years) with high total dislocation of the hip. All the patients had severe hip pain. In all cases, femoral shortening by subtrochanteric segmental resection and an anatomical reconstruction of the acetabulum were performed with the use of cementless femoral components and cementless acetabular components with screws, respectively. The Harris hip scoring system was used for functional assessments. Radiologic assessments were based on the DeLee and Charnley criteria for the acetabular component, and on the Gruen zones and the Engh criteria for the femoral component. The mean follow-up period was 44 months (range 22 to 79 months). RESULTS Union was achieved in all cases in a mean of 14 weeks (range 11 to 15 weeks). The mean leg length discrepancy decreased from 4 cm to 1.5 cm postoperatively. A positive Trendelenburg sign was found in 13 patients and four patients before and after surgery, respectively. The mean Harris hip score improved from 37 to 83 postoperatively. None of the patients developed deep infection, dislocation, sciatic nerve palsy, or nonunion at the osteotomy site. No clinical and radiologic signs of loosening were observed and no revisions were required. CONCLUSION Femoral shortening with subtrochanteric segmental resection in THR is a safe technique in patients with high total dislocation of the hip, leading to satisfactory functional results.

The evaluation of hip muscles in patients treated with one-stage combined procedure for unilateral developmental dysplasia of the hip: part I: MRI evaluation.

Background To assess the status of hip flexor and extensor muscles with MRI in patients with unilateral developmental dysplasia of the hip (DDH) after walking age who were treated with one-stage combined procedure. Methods Twenty-two patients operated upon with one-stage combined procedure for unilateral DDH were included in this study. All patients underwent complete tenotomy of the iliopsoas muscle hindering open reduction. All patients showed excellent results according to the modified McKay criteria of Barrett and type 1 hips according to radiologic criteria of Severin at the latest follow-up. MRI assessment of iliopsoas, rectus femoris, tensor fasia lata, sartorius, and gluteus maximus muscles was performed and muscles of the hip that was operated upon were compared with the hip that was not. In addition, the iliopsoas muscle was examined for reattachment and the effect of reattachment was evaluated. Results Mean age was 154.4±34.6 (110 to 216) months. Mean follow-up was 112.6±32.0 (68 to 159) months. Reattachment of the iliopsoas was observed in 7 (32%) patients, with no significance in terms of age, postoperative follow-up period, or the duration of the postoperative period. Atrophy in the hip that was operated upon was significant in iliopsoas, rectus femoris, tensor fasia lata, and gluteus maximus muscles when compared with the hip that was not. No significance was detected in the sartorius muscle between hips that were operated upon and those that were not. Cross-sectional areas of tensor fascia lata, rectus femoris, sartorius, and gluteus maximus muscles were not significantly different between patients with and without reattachment of iliopsoas. The width of the iliopsoas muscle was significantly lowered in patients without reattachment. Conclusions Patients with DDH treated with combined procedures including complete iliopsoas tenotomy do not have hip muscles similar to hip muscles that have not been operated upon, despite excellent radiologic and clinical results. These patients can be affected by muscular changes in the long term. Follow-up by conventional radiologic and clinical criteria alone may not be enough, and patients may have problems, as in our series, that cannot be detected by conventional radiologic and clinical assessments. Level of Evidence Level IV, Therapeutic case series.

The evaluation of hip muscles in patients treated with one-stage combined procedure for unilateral developmental dysplasia of the hip: part II: isokinetic muscle strength evaluation.

Background To assess the isokinetic muscle strength (IMS) of hip flexor and extensor muscles in patients treated with one-stage combined procedure for developmental dysplasia of the hip and analyze the effect of the status of hip muscles on IMS. Methods Twenty-two patients were included in the study. The mean age was 154.4±34.6 (110-216) months and the mean follow-up was 112.6±32.0 (68-159) months. All patients underwent complete tenotomy of the iliopsoas muscle to ease open reduction and had excellent results according to the modified McKay criteria of Barrett and type I hips according to the radiologic criteria of Severin. All patients had earlier magnetic resonance imaging examination that revealed reattachment of the iliopsoas in 7 (32%) patients. IMS measurements were performed at 120 degrees/s and 240 degrees/s. The peak torque (PT), PT angle, total work (TW), and average power (AP) values of operated and nonoperated hips were recorded separately for flexors and extensors. Results For flexors, TW and AP values were lower at the operated hip when compared with the nonoperated hip at both angular velocities. PT was only lower at the operated hip at 120 degrees/s. For extensor muscles, PT, TW, AP, and PT angle showed no statistically significant difference at either angular velocity. For flexors, the PT deficit between the operated and nonoperated hips at 120 degrees/s and 240 degrees/s was measured as 15.3% and 8.0%, respectively. There was no difference between the flexor muscles of operated and nonoperated hips considering PT, TW, and AP at both angular velocities in patients with reattachment. The IMS deficit of flexor muscles at 120 degrees/s was significantly higher in patients without reattachment of iliopsoas when compared with those with reattachment, and correlated to the widths of the iliopsoas muscle at levels II and III. Conclusions Assessing the results of surgical treatment of DDH with conventional radiologic and functional criteria might be misleading in some patients with excellent results because some of these patients, particularly those without reattachment of the iliopsoas muscle, experience significant weakness in hip flexion. Level of Evidence Level IV, therapeutic case series.