Murat Demirel

A giant extrasynovial osteochondroma in the infrapatellar fat pad: end stage Hoffa’s disease

The infrapatellar fat pad of Hoffa is commonly injured but rarely discussed in the orthopaedic literature. Hoffa’s disease is the extension of various traumatic events due to impingement and inflammation of the infrapatellar fat pad and known as a vague reason for anterior knee pain. Inflammation is foreground during acute phase of the disease while impingement due to fibrosis and scar tissue of infrapatellar fat pad plays a major role in the chronic phase. The osteochondroma of the infrapatellar fat pad secondary to the Hoffa’s disease can be more problematic. Although, the fibrocartilaginous transformation and osteochondral metaplasia of infrapatellar fat pad was pointed out frequently in the literature, the published papers seem far from clarifying the relation between chronic impingement and formation of osteochondroma. We present a case of a giant ossifying chondroma in the infrapatellar fat pad that resulted from chronic Hoffa’s disease. Complete open resection was performed successfully after arthroscopic examination. The infrapatellar fat pad contains the entire progenitor cells for the development of an osteochondroma and chronic impingement may have promoter affect on this issue, thus, an osteochondroma may occur at the end-stage Hoffa’s disease.

Interlocking nailing of humeral shaft fractures a retrospective study of 114 patients

BACKGROUND Fractures of the humeral shaft are relatively common injuries. Literature suggests that humeral shaft fractures represent approximately 3 % of all fractures. There are several modalities for the management of diaphyseal humeral fractures. The latest investigations emphasize the concept of minimal exposure and rigid fixation. AIM The aim of the study is to evaluate the results of antegrade intramedullary nailing in humeral shaft fractures. DESIGN A retrospective review. SETTINGS Patients were treated in private hospital settings by 3 orthopaedics surgeon. MATERIAL AND METHODS Between 1995 and 2003, the technique of antegrade locked intramedullary nailing with UHN in humeral shaft fractures was performed on 114 patients. Forty-two (36%) patients sustained multiple traumas, and 22 (19%) fractures were open. The outcomes were evaluated with a mean follow-up of 41 months. STATISTICAL ANALYSIS USED Ranges of results given. RESULTS In 109 fractures primary union observed. In the other five patients union achieved after removal of the nail and fixation with DCP and bone grafting. The average time for union was 13 weeks (range, 10-36 weeks). One hundred-five patients had excellent or satisfactory recovery of shoulder and elbow function. Complications included impingement due to proximal locking screws in two patients and prominent nail in three patients, transient postoperative radial nerve palsy in four patients. CONCLUSIONS This study shows that antegrade locked nailing in humeral shaft fractures are reliable and also effective in multiply injured patients.

Bilateral anterior glenohumeral dislocation in a horse rider: a case report and a review of the literature

A case of bilateral anterior glenohumeral dislocation in a middle aged horse rider was presented. The patient was an amateur rider who sustained the injury when the horse reared suddenly. The rider fell back from the saddle while holding the halter. The shoulders were dislocated by a violent traction when shoulders were in internal rotation and flexion in sagittal plane and slight abduction in coronal plane. To the best of our knowledge this case is the third glenohumeral dislocation by forward traction. A review of the literature is presented.

Augmented repair of acute tendo Achilles ruptures with gastrosoleus turn down flap.

Background: We present the results of primary repair of acute tendo Achilles (TA) rupture augmented with gastrosoleus turn down flap technique. Patients and Methods: 78 consecutive patients with a complete acute rupture of the Achilles tendon operated between 1993 and 2004 were included in study. We performed a modification of the Lindholm technique in which the primary Kessler suture repair of the tendon was augmented by a turn-down ~3 cm × 10 cm gastrosoleus aponeurosis flap. In all cases, a short-leg circular walking cast was applied at 90° of the ankle dorsiflexion for 3 weeks and all the patients were encouraged to full weightbearing ambulation immediately. After removal of the cast, isometric and isokinetic ankle exercises were performed for 3 weeks. Modified Rupp Score was used to evaluate the subjective satisfaction. Results: All of patients returned to daily activity and 54 (69%) of them returned to previous sport activity. The tendon repair failed in two patients and they were reoperated with an allograft. Three patients developed infection and one of them required débridement. One developed deep venous thrombosis and two permanent sural nerve injuries were encountered. One of the patients had a severe skin necrosis, which was treated with rotation flap. The mean Rupp score was 29 (3–33). Conclusion: Primary repair of acute tendo Achilles rupture augment with gastrosoleus turn down flip technique in combination of immediate weightbearing ambulation provides a good outcome, but is associated with similar complication rates to the previous literature.

Achilles tendon rupture: physiotherapy and endoscopy-assisted surgical treatment of a common sports injury

Although the Achilles tendon (AT) is the strongest tendon in the human body, rupture of this tendon is one of the most common sports injuries in the athletic population. Despite numerous nonoperative and operative methods that have been described, there is no universal agreement about the optimal management strategy of acute total AT ruptures. The management of AT ruptures should aim to minimize the morbidity of the injury, optimize rapid return to full function, and prevent complications. Since endoscopy-assisted percutaneous AT repair allows direct visualization of the synovia and protects the paratenon that is important in biological healing of the AT, this technique becomes a reasonable treatment option in AT ruptures. Furthermore, Achilles tendoscopy technique may decrease the complications about the sural nerve. Also, early functional postoperative physiotherapy following surgery may improve the surgical outcomes.

Translation, cross-cultural adaptation, reliability and validity of the Turkish version of the Olerud-Molander Ankle Score (OMAS)

Objective The aim of this study was to translate and culturally adapt the Olerud-Molander Ankle Score (OMAS) into Turkish and to assess its reliability and validity. Methods The Turkish version of the OMAS (OMAS-Tr) was developed after the translation and back-translation, which included the stages recommended by Beaton. The OMAS-Tr was administered to one hundred patients (49 females, 51 males; average age: 42.3 ± 17.7; range 16–81 years) with malleolar fractures. The OMAS-Tr was completed twice by each participant at 7- to 10-days intervals to assess test-retest reliability based on the interrater correlation coefficient, whereas Cronbachs alpha evaluated internal consistency. The external validity was evaluated with correlations between the Turkish version of the Foot and Ankle Ability Measure (FAAM) and the Turkish version of the SF-12 questionnaire. The distribution of floor and ceiling effects was also analyzed. Results The internal consistency (Cronbachs α = 0.84) and the test-retest reliability (ICC = 0.98) were excellent. The mean interval between the two tests was 8.6 ± 1.4 days. The mean and standard deviation of the first and second assessments of the OMAS-Tr were 74.1 ± 23.7 and 75.7 ± 23.9, respectively. There was a strong correlation between the OMAS-Tr and the FAAM subscales on activities of daily living and sports (r = 0.86, r = 0.83; p < 0.001, respectively). The OMAS-Tr displayed very good to good correlation with the SF-12 physical component score and the SF-12 mental component score (r = 0.72, r = 0.60, p < 0.001, respectively). Conclusion OMAS-Tr was a valid and reliable tool to assess ankle fracture-related problems. Nonetheless, further studies are needed to assess its responsiveness. Level of evidence Level III, diagnostic study.

Simultaneous ACL–PCL reconstructions with high tibial osteotomy: salvage for an unstable arthritic knee

We present a case of a 28-year-old man with a severe osteoarthritic varus knee after a neglected multiligamentous injury sustained 10 years prior. Simultaneous anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) reconstructions with high tibial osteotomy (HTO) were performed at a single stage. Five years after surgery, there were no signs of effusion and no instability, and the patient could easily kneel down without any discomfort. We think that salvage procedures and biological reconstructions would be the primary choice of surgical treatment in young patients to delay arthroplasty, and it is possible to perform simultaneous reconstructions of ACL and PCL with HTO in a single stage.

Cartilage repair strategies in the knee: A survey of Turkish surgeons

Objectives The purpose of this study was to analyze the trends in cartilage repair strategies among Turkish orthopedic surgeons for isolated focal (osteo)chondral lesions of the knee joint. Materials and methods A web-based survey of 21 questions consisting of surgical indications, techniques and time to return to sports was developed to investigate the preferences of members of the TOTBID and the TUSYAD. Results A total of 147 surgeons answered the questionnaire.70% of the respondents were TUSYAD members. 82% of respondents had at least five years experience in arthroscopy. Half of the surgeons indicated that patient age of 50 was the upper limit for cartilage repair. Irrespective of activity level, microfracture (60–67%) was the most frequently used technique for lesions smaller 2.5 cm2. In lesions larger than 4 cm2, MACI was the most commonly advocated procedure (67%). In patients with high activity levels, mosaicplasty was the first choice (69%) for lesions between 2.5 and 4 cm2 in size, followed by MACI (27%). Conclusion Patient age, activity level, BMI and lesion size were important determinants for the choice of treatment of isolated chondral lesions in the knee. These results reflect the choices of experienced knee surgeons in the country. Although not widely performed in Turkey and has limited reimbursement by the health care system, the first choice for defects over 4 cm2 was second generation ACI. Third party payers & health reimbursement authorities should take into account that large defects require methods which are relatively expensive and need high technology. Cross-sectional survey, Level II.

Cartilage Repair Approach and Treatment Characteristics in the Knee Joint: A Turkey Survey.

Objectives: To determine the approaches of Turkish Orthopaedic and Traumatology specialists towards the treatment of isolated focal cartilage lesions in the knee joint. Methods: An online questionnaire consisting of 21 questions was prepared and sent to a sample group comprising members of the Turkish Orthopaedics and Traumatology Association (TOTBID) and the Turkish Sports Injuries Arthroscopy and Knee Surgery Association (TUSYAD). The responses of 129 members were evaluated. Results: Of the total respondents to the questionnaire, approximately 1/3 worked in a private hospital, 1/3 in a university, 15% in a state hospital and 13% in a training and research hospital. An arthroscopic approach was applied fewer than 50 times per year by 20% of respondents, 50-100 times by 40%, 100-200 times by 24% and more than 200 times by 17%. The upper age limit for surgical repair of cartilage was reported as 50 years by 52% and 40 years by 25%. Similarly, the body mass index (BMI) upper limit was stated as below 30kg/m2 by 58% and below 25kg/m2 by 22%. The best results were thought to come from femoral condyle lesions by 85% of the surgeons. In patients with high activity expectations, the most frequently applied methods were 60% microfracture and 40% mosaicplasty. For lesions between 2.5 and 4cm2 in size, mosaicplasty was applied most often, followed by matrix-supported chondrocyte implantation. In lesions larger than 4cm2, MACI was the most common procedure. Although 70% of surgeons had never applied the matrix-supported microfracture method, 30% considered that it could be a choice for individuals with a high activity level. A return to sports following cartilage repair was accepted as 6 months for microfracture (86%), 9 months for mosaicplasty (63%), and 12 months for matrix-supported autologous chondrocyte implantation (73%). Conclusion: As there was a similar distribution of experienced and less experienced surgeons among the respondents, the results obtained from the questionnaire are significant in terms of reflecting the general perspective in the country. That mosaicplasty was the first choice for lesions over 2.5cm2 in individuals with a high activity level may be related to poor long-term results of microfracture in large defects. Although it is not widely used in our country and social security repayments are limited, it was noteworthy that for defects over 4cm2, the first choice was second generation autologous chondrocyte implantation. Similarly, it is significant that a third of the surgeons stated matrix-supported microfracture as a choice for high activity patients, although it is not often applied. Decision makers in institutions making repayments should take into account that large defects require methods which are relatively more expensive and need high technology. The results obtained here of an upper age limit of 50 years and BMI below 30kg/m2 for cartilage repair are consistent with literature. A return to sports is planned as 6 months at the earliest and a longer period after more complex surgery.