Kemal Gökkuş

Dysplasia Epiphysealis Hemimelica of the Ankle Joint: A Case Report:

Dysplasia epiphysealis hemimelica is a rare non-hereditary epiphyseal disease that mimics synovial chondromatosis of the joints. The disease mainly targets long bones of the lower extremities and tarsal bones. We report one such case manifesting in the lateral tibia of a 13-year-old boy. He presented with a 7-month history of pain and a bony mass (3×4 cm) at the right ankle. The mass restricted ankle dorsiflexion over the lateral malleolar area. It was ossific with a lobulated appearance and reached the marrow with the underlying epiphysis and adjacent bones. The mass was excised completely from the epiphysis. The detached syndesmos was sutured anatomically.

The influence of vertebral instability on peridural circulation and concomitant peridural fibrosis formation

An animal model of vertebral instability was used to analyze the effect of chronic lumbar instability on the peridural vasculature and fibrosis formation. Fifty mature male domestic rabbits were divided into five equal groups. The vertebral instability was performed by excision of supra and interspinous ligaments between L2-L3 and L3-L4, excision of transverse and spinous processes and making bilateral laminectomies and facetectomies in groups I, II, III and IV. In group V only para vertebral muscle dissection was performed without vertebral instability. The simulation of the long term effects of overuse model on unstable spines (chronic instability) were performed with the use of Electrical Neuromuscular Stimulator to simulate cyclic flexion–extension movement in groups I, II. The rabbits in group I and III were sacrified for the histological evaluation at postoperative fifth day. The rabbits in groups I II, IV and V were sacrified at postoperative 21st day. There was no peridural venous endothelial injury or stasis but there was an increased amount of polymorph nuclear leukocytes in both group I (unstable-overuse) and group III (unstable-no overuse) after sacrification at postoperative fifth day. Peridural fibrosis and also vascular changes with different grades were seen in group II, VI and V after sacrification at postoperative 21th day. The grade of the venous changes and the mean amount of peridural scar formation were prominently higher in group II (unstable-overuse) than in group IV (unstable-no overuse) and V (control group). There was no difference between group IV and V for peridural scar formation and vascular changes. In conclusion, the instability of the lumbar spine with overuse could be a cause of peridural venous circulatory impairment, resulting in fibrosis formation.

Transpedicular decancellation osteotomy in the treatment of peridural fibrosis.

Abstract From 1992 to 1997 a series of 12 multiply operated (averaging 2.5 previous operations) patients with recurrent peridural fibrosis and postlaminectomy kyphosis underwent surgery at our clinic. The surgery was designed to restore the physiological lordosis and relax tethered cord and epidural veins by transpedicular decancellation osteotomy at a vertebra other than the vertebra with peridural fibrosis. This paper presents the long-term functional outcome of these 12 patients. Clinical assessments were conducted pre-operatively and at 3-month intervals postoperatively and included X-ray assessment and evaluation of the patients’ functional status by Oswestry Disability Index (ODI) and of pain by visual analogue scale (pain VAS). All symptoms and the pain due to peridural fibrosis disappeared in the early postoperative period. Patients had lower disability and pain scores at their early and long-term follow-ups (follow-up period 24–74 months, mean 36.3 months). For patients with failed medical therapy for peridural fibrosis accompanied by lumbar kyphosis or hypolordosis, transpedicular decancellation osteotomy should be the surgical treatment of choice.

Trevor’s disease: mimicking anterior ankle impingement syndrome: case report

AbstractThis report concerns an unusual cause of anterior ankle impingement. The case of a young male with Trevor’s disease mimicking an anterior spur of the ankle that resulted in anterior impingement and treated with ankle arthroscopy is presented. The aim of this study is to explain the different diagnostic properties of Trevor’s disease from a classic anterior spur. Level of evidence IV.

Solitary osteochondroma of ischial ramus causing sciatic nerve compression.

We present a 25-year-old male case of osteochondroma originating from ischial ramus which causes sciatica. The pelvic involvement is rare. Iliac crest of the pelvis is often involved. Ischial ramus involvement is extremely rare. In this article, we presented a rare case of ischial ramus involvement that misleading the physician to L4-L5-S1 radiculopathy.

Myositis ossificans circumscripta, secondary to high-velocity gunshot and fragment wound that causes sciatica.

This report concerns an unusual cause of sciatica. The case presented is of a young man with myositis ossificans that resulted in sciatica and was treated with en bloc excision and low-dose radiotherapy and indomethacine. The aim of this study was to explain the different diagnostic properties of myositis ossificans around the hip and non-classic causes of sciatica.

Limited distal clavicle excision of acromioclavicular joint osteoarthritis.

INTRODUCTION Resection of the distal aspect of clavicle has a well-documented treatment modality in case of acromioclavicular joint osteoarthritis resistant to conservative treatment. HYPOTHESIS Limited (mean ∼0.5cm distal end of clavicle resection) distal clavicle excision of A-C joint arthritis in cases resistant to conservative treatment may reduce the pain and improve the shoulder function. MATERIAL AND METHODS In this study, we retrospectively evaluated the results of limited distal clavicle excision of acromioclavicular joint osteoarthritis resistant to conservative treatment. All patients were evaluated by using the Visual Analogue Scale (VAS) and UCLA shoulder rating scale (University of California Los Angeles), either before surgery or final follow-up period for pain and functional results, respectively. RESULTS A total of 110 patients (48 male, 62 female) with AC joint arthritis, treated between the years of 2008-2012, were retrospectively analyzed. A total of 30 patients (12 male, 18 female) who failed to show improvement with conservative treatment underwent limited surgical open excision of distal clavicle. The mean age of the study population was 52.5±1.2 years. The mean follow-up period was 27±1.3 months. The mean preoperative VAS score was 83.6±5.58 (range, 70-90) while mean VAS was 26.6±9.3 (range, 10-50) at the final follow-up. There was a statistically significant difference between pre- and postoperative VAS scores in patients who had treated by surgical approach (P<0.001). The mean UCLA score of the patients increased postoperatively from 11.5 (range, 9-14) to 29.2 (range, 27-32) at the final follow-up. There was a statistically significant difference between the two time periods with respect to UCLA scores (P<0.001). DISCUSSION AND CONCLUSION In patients with AC osteoarthritis resistant to conservative therapy, the hypothesized limited clavicle excision (mean ∼0.5cm distal end of clavicle resection with preserving coracoclavicular ligaments and inferior capsule) reduced the pain and improved the shoulder function. CONCLUSION Our midterm follow-up (mean 27 months) results showed that limited distal clavicle excision of patients with AC joint osteoarthritis resistant to conservative treatment (0.5cm distal end of clavicle resection with preserving inferior capsule, and coracoclavicular ligaments) reduced the pain and improved the shoulder function. LEVEL OF EVIDENCE IV (Retrospective study).

Degenerative arthritis of pseudoarticulation between the os peroneum and cuboid: A rare cause of lateral foot pain

The painful os peroneum syndrome is widely recognized. It is often the result of trauma. However degenerative changes between the os peroneum and the articular facet is much rarer and we could only find two other case reports in the literature. This report concerns a middle aged woman with chronic plantar-lateral foot pain and a limp secondary to degenerative changes between the os peroneum and its articular facet with cuboid. The aim of this study is to remind to orthopaedic surgeons about painful os peroneum syndrome and to highlight the rarity of our case. In our case the mid term result of the excision of the os peroneum with painful articulation appear good, providing symptomatic pain relief with little alteration in the function of the foot.

Solitary synovial osteochondroma of the knee: mimicking a giant loose body

Solitary synovial osteochondromas are rarely seen. Usually arising from the juxta-articular soft tissues without attaching to the bone, these lesions can be large and show clinical and radiological features of a malignant process. This report is about a 64-year-old woman with no history of trauma. She had a history of dull pain and a progressive limited range of motion that had been ongoing for 3 years. An unusual presentation of an uncommon disease that is not widely known by orthopedic surgeons is reported.

Trevor's disease: up-to-date review of the literature with case series.

Trevor’s disease, also known as dysplasia epiphysealis hemimelica, is a rare nonhereditary skeletal development disorder that affects epiphyses. This type of dysplastic lesion was first reported by Mouchet and Berlot in 1926 under the name ‘tarsomegaly’. The main aim of this study is to raise awareness of Trevor’s disease among orthopedic surgeons and underline some important aspects of treatment by a detailed presentation of four different possible manifestations of the disease. Four different treatment methods were used on four different patients (three localized in hindfoot ankle region and one classic Trevor’s disease case). Treatment methods, localization of the sides involved, different characteristics of entire lower extremity, asymetry, distal femoral lateral epiphysis involvement, and hip involvement were analyzed thoroughly and the results were compared with those found in the most recent literature. Of our four patients, three were localized (hind foot ankle) cases and one was a classic dysplasia epiphysealis hemimelica with hemimelic distribution of the entire lower extremity. We used arthroscopic resection, observation, excision, and temporary hemiepiphysiodesis treatment methods in each of our cases. Clinical follow-up results were reported to be between good and excellent. In sum, our opinion is that the treatment for this condition should be customized according to lesion localization and lesion size. Majority of cases with ankle involvement show good prognosis following excision. Observation is also an alternative in patients who refuse surgery. If an intra-articular lesion is present, the surgeon should perform an arthroscopy for assessment of lesion surface. If the lesion is adapted to the joint curvature, it should be left alone and hemiepiphysiodesis should be considered for correction. The most risky involvements that are related to deformities and limb-length discrepancies are the hip and the knee. This is usually the result of corrective osteotomy targeted at the supracondylar femoral area in immature skeletons. Hemiepiphysiodesis might be a more feasible option in those cases as it provides the surgeon with the choice to remove the staples when necessary.