Mehmet Demirel

Hip fractures in patients older than 75 years old: Retrospective analysis for prognostic factors

BACKGROUND Proximal femoral fractures are often seen in older patients and are associated with high mortality. Introduction to old age population is latening due to advancements in medical sciences and increasing life expectancy. OBJECTIVES The aim of the study was to evaluate factors affecting mortality in patients above 75 years of age who had been operated because of proximal femur fractures. PATIENTS AND METHODS Patients with age 75 and over who suffers from post-fall proximal femoral fracture who underwent surgery with one of following three methods (hemiarthroplasty, proximal femoral nail or total hip arthroplasty) were evaluated retrospectively. Effects on mortality were examined for factors such as type of surgery, type of anesthesia, preoperative ASA score (American Society of Anesthesiologists Score), need for intensive care, need for blood transfusion, operation waiting time and hospitalization duration. 115 patients who met inclusion criterion were included in the study out of 224 overall. 75 patients were women and 40 were males. RESULTS Mortality rate after first year was found to be 40%. Patients over 85 years old had higher rates of mortality (p = 0,0003) than respectively younger patients (75-85). Sex was found to have no impact on mortality (p = 0.5039). There was no statistically significant difference in terms ASA score (p = 0.1518). Order of applied surgical methods with mortality risk rates was found to be total hip arthroplasty > hemiarthroplasty > proximal femoral nail (p = 0.0003). Type of anesthesia, the use of cement during arthroplasty, operation waiting time and hospitalization duration was not directly related with mortality rate (type of anesthesia p = 0.63, the use of cement during arthroplasty p = 0.223, operation waiting time p = 0.5 and hospitalization duration p = 0.19). CONCLUSIONS Age is the primary risk factor on first year mortality in patients older than 75 years old with hip fractures. Addition to older age, more need to blood transfusions, and arthroplasty are other risk factors for first year mortality. It should be kept in mind that after 75 years old first year mortality may be higher if the patient is treated with arthroplasty.

An Unusual Traumatic Presentation: Luxatio Erecta Humeri and Concomitant Hip Dislocation

Introduction. Inferior dislocation of the glenohumeral joint, known as luxatio erecta humeri, and posterior hip dislocation are both rare presentations in the emergency department. The most common aetiology is falling for luxatio erecta humeri. The aim of this manuscript was to present a unique case in terms of luxatio erecta humeri, which has a different aetiology, treatment method, and concomitant injury. Presentation of Case. We report a construction worker who was rescued from a collapsed building who presented with both luxatio erecta humeri and complex posterior hip dislocation. An orthopaedic surgeon reducted luxatio erecta humeri with a one-step reduction technique under procedural anaesthesia as soon as the patients vital signs were stable. Discussion. Different concomitant injuries and various injury mechanisms have been described in regard to inferior shoulder dislocation in the literature. However, posterior dislocation of the hip as a concomitant distant region injury and trapping as an injury mechanism for luxatio erecta humeri are being described for the first time in this case report. Two reduction manoeuvers, one-step and two-step, have been used for this dislocation. Some authors suggested that a two-step manoeuver can be more easy to apply. In our specific case, luxatio erecta was easily reducted by a single operator in a single attempt. Conclusion. Luxatio erecta humeri may occur from trapping and complex injuries can accompany luxatio erecta humeri in patients with multiple trauma. A one-step closed reduction can be easily applied by a single operator under procedural anaesthesia.

Intraneural ganglion cyst of the ulnar nerve in an unusual location: A case report

Highlights • Intraneural ganglion cysts are benign, mucinous, non-neoplastic lesions of the peripheral nerves that arise from the epineurium.• An intraneural ganglion cyst involving the superficial branch of the ulnar nerve is a unique presentation.• Regarding etiopathogenesis of the intraneural ganglion cysts, the latest and most affirmed theory is the unifying articular (synovial) theory.• It is important to realize a related articular branch, otherwise the origin of cyst formation remains, and this may cause other para-articular cysts.• Use of new 3-dimensional fast-spin echo-extended echo train MRI sequences may provide better visualization of the intraneural ganglions.

Adolescent Anterior Inferior Iliac Spine Avulsion Fracture Operative Treatment: A 14-Year Follow-Up Case Report

Objectives: Pelvic apophysis injuries are generally seen in adolescents and encountered in the form of avulsion fractures which occur with the short-term contractions of the muscles that hold apophysis, following a trauma. In general the iliac crest, the anterior superior iliac spine (ASIS) and the pubic bone fractures are frequently seen but anterior inferior iliac spine (AIIS) fractures are rare. These cases are often treated conservatively, surgical treatment is rarely necessary. In this presentation, AIIS avulsion fracture case that had undergone surgery and had been followed for 14 years was aimed to be stated. Methods: 16 year old male patient who was suffering from sports injuries that happened 40 days ago was admitted to our clinic in February 2000 with complaints about left hip and groin pain. Physical examination and radiographic evaluation of the patient identified left hip AIIS avulsion fracture. Due to more than 2 cm fracture fragment displacement and the patient being a professional football player who had high functional expectations, surgical treatment was planned. Under general anesthesia, after open reduction, internal fixation was performed with 1 cannulated screw. There were no complications observed at follow-up. Patient returned to training at 3 months postoperatively. 14 years after surgery, the patient admitted to a neurologist with complaints of headache and MRI was required to establish the cause. The patient admitted to our clinic in order to get the confirmation whether his implant was MRI compatible. Results: On clinical assessment, after 14 years, the patient didn’t have any complaints at left hip. Left hip flexion was 120°, extension was full, abduction was 40°, adduction was 20°, flexion internal rotation was 30° and flexion external rotation was 40°. Radiographs of the pelvis were normal. On the patients functional assessment, modified Harris Hip Score was 100. Conclusion: Pelvic apophysis injuries are rare injuries seen in adolescents usually as avulsion fractures. These injuries are often treated conservatively however may require surgical treatment for professional athletes with a high functional expectations. In this patient who underwent surgery, at the end of the 14-years long follow-up, functional results were found to be close to perfect.

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.

Concomitant rhomboid-shaped tibiae and fibulae, finger-like projections, and orthopedic management in a new variant of nievergelt syndrome: A case report

Highlights • The rare Nievergelt syndrome (NS) is the most severe form of mesomelic dysplasia and is characterized by disproportionate shortness of the limbs.• The primary phenotypic characteristics include a rhomboid-shaped tibia and overgrown fibula with bony protuberances and skin dimples.• These finger-like projections and concomitant rhomboid-shaped tibiae and fibulae should be kept in mind for the NS.• The limb lengthening and deformity corrections using an external fixator could be considered in the orthopedic treatment of the NS.• A preoperative evaluation of the vascular status could prevent several postoperative complications.

New trends in the orthopaedic management of diabetic foot

Although there are various types of therapeutic footwear currently used to treat diabetic foot ulcers (DFUs), recent literature has enforced the concept that total-contact casts are the benchmark. Besides conventional clinical tests and imaging modalities, advanced MRI techniques and high-sensitivity nuclear medicine modalities present several advantages for the investigation of diabetic foot problems. The currently accepted principles of DFU care are rigorous debridement followed by modern wound dressings to provide a moist wound environment. Recently, hyperbaric oxygen and negative pressure wound therapy have aroused increasing attention as an adjunctive treatment for patients with DFUs. For DFU, various surgical treatments are currently available, including resection arthroplasty, metatarsal osteotomies and metatarsal head resections. In the modern management of the Charcot foot, surgery in the acute phase remains controversial and under investigation. While conventional fixation techniques are frequently insufficient to keep alignment postoperatively, superconstruct techniques could provide a successful fixation. Retrograde intramedullary nailing has been a generally accepted method of achieving stability. The midfoot fusion bolt is a current treatment device that maintains the longitudinal columns of the foot. Also, Achilles tendon lengthening remains a popular method in the management of Charcot foot. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170073

Treatment of Graf Type IIa Hip Dysplasia: A Cutoff Value for Decision Making

Background: The rate of spontaneous normalization in type IIa hips is reported to be high, whereas dysplsia persists or worsens in 5%-10% of cases. Aims: To evaluate the natural course of type IIa hips using Graf’s own perspective of physiological immaturity and maturational deficit. Study Design: A single center, retrospective cohort study. Methods: This was an institutional review board-approved retrospective review of all patients diagnosed with type IIa hip dysplasia at a single institution from 2012 to 2014. All patients included in the study had hip ultrasonography at about 6 weeks and 3 months of age. To assess reliability in α and β angles, ultrasonography measurements were carried out on the same image individually by all observers. The α and β angles were used as the main outcome measurements to evaluate hip maturation at the last follow-up. A receiver operating characteristics curve was drawn at the 3 month ultrasonography to evaluate the cut-off values for α and β angles for persistent dysplasia. Results: Sixty-four patients and 88 affected hips (63% unilateral and 37% bilateral) were included. The mean age at diagnosis was 6.4±2.7 weeks. Fifty-four hips were type IIa(+) (physiologically immature) and 34 hips were type IIa(-) (maturational deficit) at the initial ultrasonography evaluation. Improvement to type I was seen in 52 type IIa(+) and 17 type IIa(-) hips. Receiver operating characteristic analyses showed that patients do well if the α angle was >55° (area under the curve: 0.86; p<0.001 for the left hip and area under the curve: 0.72; p=0.008 for the right hip). Conclusion: The cut-off α angle value of 55° on initial ultrasonography should be considered to prevent future dysplasia. An α angle <55° on the initial ultrasonography was an independent predictor of worsening sonographic findings.

TOPUK AĞRISININ NADİR BİR NEDENİ, KALKANEUS YERLEŞİMLİ İNTRAOSSEÖZ LİPOM: 9 OLGUNUN RETROSPEKTİF ANALİZİ ve LİTERATÜR DERLEMESİ

Amac: Intrakalkaneal lipom nadir gorulur ve siklikla asemptomatiktir. Semptomatik olan vakalarda ise cogunlukla ilk ve en sik sikâyet basit topuk agrisidir. Bu calismanin amaci, topuk agrisi sebebiyle basvurduklari kliniklerde cesitli on tanilar alarak cerrahi disi yontemler ile tedavi edilmeye calisilan ve klinigimizde cerrahi olarak basariyla tedavi edilmis 9 olgunun retrospektif analizini ve literatur derlemesini sunmaktir. Gerec ve Yontem: Klinigimizde 2008 ve 2015 yillari arasinda intrakalkaneal lipom tanisi ile ameliyat edilen 9 hasta (4 kadin, 5 erkek) calismaya dahi edildi. Ortalama yas 40,6 (19-70) yil idi. Ortalama takip suresi 50,4 (12-114) ay idi. Baslangictaki yanlis tani ile gercek tani arasindaki sure 20,8 (12-48) ay idi. Hastalar klinigimize basvurmadan once, Achilles tendiniti, epin kalkanei, retrokalkaneal bursit ve plantar fasiit tanilari almis ve tedavi edilmeye calisilmistir. Bulgular: Yedi hasta kuretaj & kemik grefti ve 2 hasta kuretaj & kemik sementi ile tedavi edildi. Tum hastalar ortalama 5 (3-11) ayda tamamen agrisiz iyilesti. Kemik greftlerinin tam olarak konsolidasyonu ortalama 6 (5-9) ayda goruldu. Ortalama AOFAS skoru ameliyat oncesi 80,4 ten birinci yilda 95,3’e yukseldi. Sonuc: Topuk agrisi olan hastalarda intrakalkaneal lipom ayirici tanida dusunulmelidir. Kuretaj ve kemik grefti ile grefonaj agrili ve kritik boyutta intrakalkaneal lipomlar icin iyi bir cerrahi tedavi secenegi olabilir. Anahtar kelimeler: Topuk agrisi; kemik ici lipomlar; kalkaneus.

Posterior interosseous nerve palsy associated with neglected pediatric Monteggia fracture-dislocation: A case report

Highlights • The main goal of the treatment is the anatomical reduction of the ulna fracture and the radial head dislocation in acute and chronic Monteggia cases.• The most commonly preferred technique is open reduction with ulnar osteotomy.• The radiocapitellar joint is very sensitive to ulna length.• To decide whether to repair or reconstruct the annular ligament remains controversial.• Anatomic and stable restoration of radiocapitellar joint by correcting ulna deformity may be performed.