Hayrettin Kesmezacar

Localized pigmented villonodular synovitis of the knee.

Eight patients with localized pigmented villonodular synovitis (LPVNS) of the knee were treated with arthroscopic and open techniques, with diagnosis confirmed by histological examination. Average patient age was 29 years (range: 13-50 years). At arthroscopy, all lesions except one were in the anterior compartment of the involved knee. Treatment consisted of complete local excision with partial synovectomy. This procedure was completed arthroscopically in seven patients. No recurrence was reported at average 24-month follow-up (range: 12-33 months). Arthroscopy is a valuable tool in the diagnosis and treatment of LPVNS.

The results of conservatively treated simple elbow dislocations

OBJECTIVES Closed reduction followed by short-time immobilization is the generally accepted treatment for simple elbow dislocations. However, the number of studies concerning the results of this method is limited. In this study, the clinical and radiographic results of conservatively treated simple elbow dislocations were retrospectively evaluated. METHODS The study included 21 patients (16 males, 5 females) who underwent closed reduction and immobilization for simple elbow dislocations. Simple dislocations were defined as non-fracture dislocations and dislocations accompanied by minor avulsion fractures that did not require additional surgery or immobilization. The mean age of the patients at the time of injury was 35 years (range 16 to 59 years). All the patients had posterior dislocations. Eleven patients (52.4%) had minor avulsion fractures. Following closed reduction, a plaster splint and hinged brace were used in four (19.1%) and 17 (81%) patients, respectively. Incremental active and passive motions were started at the end of the first week in patients in whom a brace was used. The mean duration of brace use was 27 ± 16 days. Patients using a plaster splint were immobilized for three weeks. The patients were assessed clinically with respect to range of motion, instability, and neurologic findings after a mean follow-up period of 34 months (range 12 to 99 months). Functional assessments included the Mayo Elbow Performance Score (MEPS) and the Broberg-Morrey Functional Rating Index (BMFRI). Standard elbow anteroposterior and lateral radiographs were examined for concentric reduction and signs of degeneration and heterotopic ossification. RESULTS Compared to the normal side, the degrees of flexion, extension, flexion arc, and pronation were significantly decreased in dislocated elbows (p<0.05), while the degrees of supination and rotational arc were similar. There was no muscular atrophy. Four patients (19.1%) had residual instability and six patients (28.6%) had mild to moderate neurological complaints that were primarily related to the ulnar nerve. Three patients complained of mild pain, and one patient complained of moderate pain at rest. Radiographic assessment showed mild degeneration in three patients (14.3%), and mild to moderate heterotopic ossification in 14 patients (66.7%). Patients with and without heterotopic ossification did not differ significantly with respect to the values of joint range of motion. The mean MEPS and BMFRI scores were 96.9 and 97.7, respectively. The scores of both systems were excellent in 20 patients (95.2%) and moderate in one patient (4.8%). The majority of the patients (81%) reported complaints about their elbows including sensation of stiffness in the elbow, pain during strenuous work or sports activities, and limitation of movement. Only four patients (19.1%) reported a feeling of full recovery. CONCLUSION Although closed reduction with short-term immobilization is a universally accepted method for simple elbow dislocations with excellent functional scores, it is associated with significant limitations in joint movements and a great majority of patients do not consider themselves fully recovered.

[Long-term results of total hip arthroplasty in patients with juvenile rheumatoid arthritis].

OBJECTIVES We evaluated the long-term results of total hip arthroplasty (THA) in patients with juvenile rheumatoid arthritis (JRA). METHODS The study included 37 hips of 23 patients (22 females, 1 male; mean age 22 years; range 17 to 30 years) who underwent THA for hip degeneration secondary to JRA. All arthroplasties were performed through an anterolateral approach by the same senior surgeon. The mean body surface of the patients was 1.5 m2 (range 1.1 to 1.7 m2) and the mean symptom duration to surgery was 12 years (range 7 to 16 years). Twenty-three hips received cemented, 14 hips received hybrid prostheses. In seven hips with an extremely narrow femoral medulla and shallow acetabulum, a CDH prosthesis was used. The hips were evaluated using the Harris hip score. Prosthetic loosening and displacement and heterotopic bone formation were assessed on follow-up radiographs. The mean follow-up period was 135 months (range 58 to 212 months). RESULTS The mean Harris hip score increased from 27.2 (range 11 to 69) to 79.5 (range 37 to 87) postoperatively. At final follow-ups, all the patients were satisfied with the outcome and were able to walk without support. Three hips (8.1%; 3 patients) required revision. The overall Kaplan-Meier implant survival rate was 86.5%. There were no significant correlations between the Harris hip score and radiographic loosening and the presence of calcification around the prosthesis. Heterotopic bone formation of grade I was observed in 17 hips (46%). CONCLUSION Even though it is performed at young ages, THA considerably improves quality of life of patients with JRA having hip joint involvement and has a comparable implant survival.

Myositis ossificans in early childhood

A 5-year-old boy underwent arthroscopic surgery because of a lateral discoid meniscus, which was followed by an overly strenuous rehabilitation program. At 6-week follow-up, a painful mass at the distal part of the thigh and a flexion restriction of the operated knee were detected, caused by myositis ossificans inside the vastus medialis muscle. The symptoms disappeared with an appropriate rehabilitation program and the patient recovered.

Functional outcome of reverse shoulder tumor prosthesis in the treatment of proximal humerus tumors.

BACKGROUND The treatment of proximal humerus tumors with reverse shoulder arthroplasty with allograft augmentation is still controversial. A tumor prosthesis represents a proven solution for such osseous defects. We investigated the functional results of patients who underwent reverse shoulder tumor prosthesis (RSTP) without the use of allograft after resection of a proximal humerus tumor. METHODS We retrospectively evaluated 10 patients with malignant proximal humerus tumors who had undergone RSTP, with a mean follow-up period of 18.2 months (range, 6-27 months). The average age of the patients was 49.4 years. The mean resection length was 10.2 cm (range, 6-16 cm). The tumor prosthesis was preferred for the humeral component. Released rotator cuff muscles were reattached to the prosthesis with nonabsorbable sutures. RESULTS The mean active forward flexion was 96° (range, 30°-160°), the mean active abduction was 88° (range, 30°-160°), and the mean active external rotation was 13° (range, 0°-20°). The mean Constant-Murley score was 53.7%. The mean Disabilities of the Arm, Shoulder, and Hand score was 26.2. The mean visual analog scale score was 1.3. The mean Musculoskeletal Tumor Society score was 78.1%. None of our patients have shown local recurrence or infection signs in the follow-up period. CONCLUSIONS Functionally satisfying results and a stable shoulder can be achieved by reverse shoulder arthroplasty without the need for an allograft. An intact abductor mechanism with a shorter resection humerus length produced good results. The treatment of malignant proximal humerus tumors with RSTP is an alternative that minimizes surgery time and complexity.

Results of displaced supracondylar humerus fractures treated with open reduction and internal fixation after a mean 22.4 years of follow-up.

BACKGROUND The aim of this study was to evaluate the long-term functional and cosmetic results as well as the sagittal and coronal plane remodeling of displaced supracondylar humerus fractures treated with open reduction and internal fixation. METHODS In total, 49 patients (11 boys and 38 girls) with Gartland type III supracondylar humerus fractures treated with open reduction and cross-pin fixation were retrospectively evaluated. The mean follow-up time was 22.4 years (range, 10.6-37.5 years). The Flynn criteria were used to assess the cosmetic and functional outcomes. Baumanns angle, the lateral rotational percentage, the humerus-elbow-wrist angle, and the humeral condylar angle were obtained from follow-up radiographs. The flexion and extension deficits compared with the uninjured side were measured at the last follow-up. RESULTS According to the Flynn criteria, the cosmetic outcomes were satisfactory in 93.9% of the patients, and the functional outcomes were satisfactory in 83.7% of the patients. The average flexion deficit was 5° ± 8°, and the average extension deficit was 4° ± 5°. At the final follow-up, the mean difference in the humerus-elbow-wrist angle and the humeral condylar angle between the injured and uninjured sides was -4° ± 7° and 0° ± 3°. CONCLUSIONS We identified the remodeling in the sagittal plane in supracondylar humerus fractures that had been united in flexion. Satisfactory functional and cosmetic results were obtained with the open reduction and internal fixation of displaced supracondylar fractures of the humerus, and no degenerative changes were observed at the long-term follow-up.

Effect of decortication on laminar strength during sublaminar wiring: an experimental study.

Eighty lumbar segments from 16 female sheep were used to investigate the effect of laminar decortication on the strength of the lamina during sublaminar wiring procedure. Sheep were 12-14 months old. Forty vertebrae from eight animals were decorticated before loading with sublaminar wire to failure, and 40 vertebrae from the remaining eight sheep were tested with the same procedure but intact. The effects of bone mineral density (BMD) and laminar dimensions on laminar strength in both decorticated and nondecorticated groups were also investigated. The failure force values of the laminae for decorticated and nondecorticated groups were 881.15 ± 36.86 and 298.48 ± 21.99 N, respectively (P < 0.001). There was a positive linear relationship between BMD and laminar strength in an intact lamina. In a decorticated lamina, no significant relationship existed between these variables. There was a negative linear relationship between mediolateral length of hemilamina and laminar strength in both intact and decorticated vertebra. Laminar strength after decortication was positively related to dorsoventral length of the remaining portion of the lamina. Decortication leads to a statistically significant decrease in laminar strength.

Bipolar or Unipolar Hemiarthroplasty after Femoral Neck Fracture in the Geriatric Population

BACKGROUND The choice of prosthesis in hemiarthroplasty is controversial for geriatric patients after femoral neck fracture. We hypothesised that selection criteria for unipolar or bipolar prostheses could be constructed based on factors affecting mortality. AIMS THE AIMS OF THIS RETROSPECTIVE STUDY WERE: (1) to determine the factors affecting mortality of femoral neck fracture patients ≥65 years of age; (2) to compare patient mortality rates, radiological findings, and functional outcomes according to prosthesis type (unipolar or bipolar); and (3) to evaluate the persistence of inner bearing mobility of bipolar prostheses. STUDY DESIGN Retrospective comparative study. METHODS In total, 144 patients operated for hemiarthroplasty and aged ≥65 were included. We classified the patients into either unipolar or bipolar prosthesis groups. To reveal factors that affected mortality, age, sex, delay in surgery, and American Society of Anesthesiologists score were obtained from folders. Barthel Daily Living, Harris hip, and acetabular erosion scores were calculated and bipolar head movement was analysed for live patients. RESULTS One-year mortality was 31.94%. Age ≥75 (p=0.029), male sex (p=0.048), and delay in surgery ≥6 (p=0.004) were the patient characteristics that were related to increased mortality. There were no significant differences in sex, age, American Society of Anesthesiologists score, delay in surgery, mortality, or Barthel, Harris, acetabulum scores between the two groups. Twenty patients from each group were admitted for last follow-up. Bipolar head movement was preserved for 33.3% of patients. They were inactive patients with low Barthel and Harris scores. CONCLUSION Although bipolar head movement was preserved in inactive patients, we suppose that this conferred no advantage to these patients, who could hardly walk. In this study, male patients, those aged ≥75 years, and those operated at ≥6 days had an increased risk of mortality. Also, although not significant in multivariate analysis, high American Society of Anesthesiologists score (≥3) was related to increased mortality. Considering that one of three patients died during the first postoperative year, we think that these patients should be operated as soon as possible, and expensive bipolar prostheses must be used selectively in regard to patient characteristics.

An ankylosing spondylitis patient ‘with no joints’

We describe a 32-year-old man with juvenile onset ankylosing spondylitis, whose first symptom was seen at 6 years of age. He was first diagnosed with oligoarticular, late-onset juvenile chronic arthritis. His diagnosis was re-evaluated when he showed bilateral sacroiliitis and positive HLA-B27. The motion capacity of the lower extremities diminished gradually following bilateral supracondylar femoral osteotomies for progressive valgus deformities and subsequent cast immobilization. For several reasons, mainly economic, his medical and orthopedic treatments were not performed until 2001. He was bedridden for 11 years and presented with no movement in the entire spinal column except for the cervical vertebrae. Radiographs revealed bony ankylosis of the hips, knees, ankles, wrists, left shoulder, left elbow, and the spinal column. Bilateral one-stage total hybrid-type hip arthroplasty and, after a rehabilitation period of 3 months, bilateral knee replacements with hinged resection prostheses were performed (Fig. 1). Twenty months after the last operation, hip function was 145 and 160 in the total range of motion. In addition to these movements, 50 and 90 of knee flexion provided him a significant improvement in his daily life. He can turn in bed, stand, and walk with crutches.