Tolga Ege

Open Mosaicplasty in Osteochondral Lesions of the Talus: A Prospective Study

Osteochondral lesions of the talus present with symptoms of pain and painful motion, affecting the quality of the patients daily life. We evaluated the 2-year short-term outcomes of patients whose large osteochondral lesions of the talus were treated with medial malleolar osteotomy and a mosaic graft harvested from the knee on the same side. A total of 32 patients who had cartilage lesions due to osteochondritis dissecans in the medial aspect of the talus underwent mosaicplasty after medial malleolar osteotomy. The patients were followed up for a mean period of 16.8 (range 12 to 24) months. The staging and treatment plan of the osteochondral lesions of the talus were made according to the Bristol classification. The follow-up protocol for the patients included direct radiography and magnetic resonance imaging. The American Orthopaedic Foot and Ankle Society scoring system was used to assess the patients during the pre- and postoperative periods. Of the 32 patients, 3 (9.4%) were female and 29 (90.6%) male, with a mean age of 27.5 (range 20 to 47) years. The mean preoperative American Orthopaedic Foot and Ankle Society score was 59.12 ± 7.72 but had increased to 87.94 ± 3.55 during the postoperative 2 years. The increase in American Orthopaedic Foot and Ankle Society score was statistically significant (p < .05). We have concluded that open mosaicplasty is a reliable and effective method for the treatment of osteochondral lesions with subchondral cyst formation in the talus, exceeding 1.5 cm in diameter.

Use of the iPhone for radiographic evaluation of hallux valgus

ObjectiveThe purpose of this study was to compare the measurements made using a smartphone accelerometer and computerized measurements as a reference in a series of 32 hallux valgus patients.Materials and methodsTwo observers used an iPhone to measure the hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (of anteroposterior foot radiographs in 32 patients with symptomatic hallux valgus on a computer screen. Digital angular measurements on the computer were set as the reference standard for analysis and comparison. The difference between computerized measurements and all iPhone measurements, and the difference between the first and second iPhone measurements for each observer were calculated. Inter- and intraobserver reliability of the smartphone measurement method was also tested.ResultsThe variability of all measurements was similar for the iPhone and the computer-assisted techniques. The concordance between iPhone and computer-assisted angular measurements was excellent for the HVA, IMA, and DMAA. The maximum mean difference between the two techniques was 1.25 ± 1.02° for HVA, 0.92 ± 0.92° for IMA, and 1.10 ± 0.82° for DMAA. The interobserver reliability was excellent for HVA, IMA, and DMAA. The maximum mean difference between observers was 1.31 ± 0.89° for HVA, 0.90 ± 0.92° for IMA, and 0.78 ± 0.87° for DMAA. The intraobserver reliability was excellent for HVA, IMA, and DMAA.ConclusionsWe conclude that the Hallux Angles software for the iPhone can be used for measurement of hallux valgus angles in clinical practice and even for research purposes. It is an accurate and reproducible method.

Prediction of the Presence of Plantaris Tendon Through Examination of Palmaris Longus Tendon: Is There a Link?

El proposito de este estudio fue investigar la relacion entre los tendones del musculo palmar largo (MPL ) y musculo plantar (MP) y poner a prueba la utilidad clinica de los patrones de simetria entre estos tendones de la poblacion turca. Estudio prospectivo realizado sobre 240 pacientes adultos (120 hombres y 120 mujeres) que ingresaron en la clinica por sintomas de dolor en la rodilla bilateralmente, quienes requerian un examen de RM de rodilla durante dos anos. Se utilizo la prueba estandar (prueba de Schaefer, se oponen el pulgar hasta el dedo minimo, mientras se flexiona la muneca) para evaluar la presencia del tendon MPL tanto con la inspeccion y palpacion. La RM de la rodilla se utilizo para determinar la presencia de vientre muscular plantar en ambos lados. Se analizo el patron de distribucion simetrica mediante la prueba de McNemar. El tendon del MPL estuvo ausente de manera unilateral en 34 pacientes (14,2%) y bilateralmente en 17 pacientes (7,1%). El tendon del MP estuvo ausente de manera unilateral en 51 pacientes ( 21,3 %) mientras que bilateralmente no estaba en 10 pacientes (4,2%). Si el tendon del MPL estuvo ausente en un lado, la probabilidad de tener un tendon del MP ipsilateral fue del 70,6 %. Si el tendon del MPL estaba presente en un lado, la probabilidad de tener un tendon del MP ipsilateral fue 87,6%. La prueba de McNemar - simetria produjo un valor p de 0,841 para los musculos PL y P ipsilaterales. Una relacion directa claro entre los tendones de los musculos PL y P no se pudo demostrar en este estudio. Ambos musculos muestran diferentes variaciones independiente uno del otro.

Postpartum symphysis pubis separation

Sir We wish to call attention to a case of symphysis pubis separation after term vaginal birth in a 41-year-old gravida 3, with insulin-regulated gestational diabetes, who previously had two spontaneous vaginal deliveries (4000 g and 3200 g babies 16 years and 11 years ago). She delivered a 4790 g baby vaginally with McRobert’s maneuver due to shoulder dystocia, but without fetal complications. Three hours after the delivery she complained of gradually increasing severe pelvic pain and difficulty in getting up and walking. Orthopedic consultation was obtained and a pelvic X-ray showed a massive 5-cm symphyseal separation (Figure 1). There was no sign of genitourinary injury/hematoma formation. She was put on strict bed rest, mostly in the lateral decubitus position, with elastic bandages wrapped around her pelvis tightly and was given paracetamol. The control X-rays on the 2nd and 3rd days showed 3-cm and 1-cm separations, showing a surprising remission. Her pain had diminished by the second day, and she was mobilized after 72 h, to be discharged at 96 h after delivery. At a control examination 7 days later she had no pain or walking difficulties. At the 3-month examination, she had no clinical symptoms of pubic diastasis, as confirmed by the orthopedic surgeon (TE) except for a known chronic lumbar discopathy. She consented for her case to be published. The pubic symphysis has the capacity to expand to facilitate delivery – this increases the sagittal diameter of the pelvic plane under the specific hormonal action of relaxin and progesterone (1). The pubic cartilage is about 4 mm, and it may reach 10 mm during the pregnancy and delivery; 10 mm is acknowledged as the highest limit for physiological distension (2). Severe symptomatic and documented postpartum symphysis pubis separation of 5 cm is an extremely rare complication. A few wider separations have been mentioned in the literature, with healing periods of around 6 weeks, however, our case showed unusually quick remission (1). The diagnosis is mainly by radiology and anteroposterior radiography is the standard diagnostic method. The factors causing intrapartum symphysis pubis separation are not known completely. The injury mechanism involves rapid, forceful descent of the fetal head into the birth canal and wedging of the head against the anterior pelvic ring, therefore creating mechanical shear forces and ligament rupture, while hyperabduction of the thighs is also blamed (1). Except for intrapartum symphysis pubis separations, pelvic ring disruptions usually involve high-energy injuries commonly observed after traffic accidents, which are classified based on the vector of force involved and the quantification of disruption from that force, i.e. lateral compression, anteroposterior compression, vertical shear and combined mechanical injury. These are conditions that require extensive surgery (3). In our case, McRobert’s maneuver with hyperabduction for the thighs for shoulder dystocia might have facilitated the complication. In conjunction with symphysis pubis separation, complications such as bladder and urethral injury and hematoma in the space of Retzius can be observed (4). When any of these complications present, suitable alternative treatment should be planned. If separation is isolated, as in our case, a conservative approach is justified with bed rest – especially in the first days as described previously (5).

Fluoroscopy for transpedicular screw placement in scoliosis: to what extent can radiation exposure be reduced by the freehand technique?

AIM In spinal surgery, high doses of radiation are delivered during surgical procedures that require fluoroscopic control. The aim of this study was to determine the amount of radiation delivered from the fluoroscopic unit and also the factors to reduce the amount of radiation during the surgery of adolescent idiopathic scoliosis patients. MATERIAL AND METHODS In this retrospective study 21 patients with adolescent idiopathic scoliosis treated by transpedicular screws between 2009 and 2012 were enrolled the study. Dose Area Product (DAP) values , number of views obtained during screw placement and other data were retrieved from the medical records of the patients. RESULTS The mean number of transpedicular screws used was 18. An average of 10,1 vertebrae were instrumented. The mean number of images obtained was 7.76. Mean fluoroscopy time was 7.95 seconds. The total mean DAP was 64.6 cGy.cm < sup > 2 < /sup > . CONCLUSION The amount of ionizing radiation transmitted to the patient and the surgical team can be reduced by freehand insertion, confirmation of screw position by AP and lateral fluoroscopic views including more than one segment, the use of K-wires as a guide in spinal segments with abnormal pedicular anatomy and neuromonitorization of the patient during the surgical correction of adolescent idiopathic scoliosis.

The importance and efficacy of posterior only instrumentation and fusion for severe idiopathic scoliosis.

AIM In mild and moderate idiopathic scoliosis (IS), posterior only instrumentation and fusion can provide satisfactory reduction. However in severe and rigid curvatures, combined anterior and posterior fusion is generally required. In this study we have aimed to evaluate the efficacy of posterior only instrumentation in severe thoracolumbar scoliosis clinically and radiologically and compare these results with the literature. MATERIAL AND METHODS In this retrospective study, 29 consecutive patients with severe idiopathic scoliosis who underwent posterior only instrumentation and fusion between March 2003 and February 2011 were included the study. Radiological evaluation was performed with preoperative, postoperative and folllow up standing AP and lateral x-rays. Clinical evaluation was made with shoulder balance and trunk shift. REAULTS: Major curve magnitude decreased to 24,1° and compensatory curve magnitude decreased to 12.20° at postoperative period. There was no significant difference in sagittal plane angles. Major curve correction rate was %68,65 in screw only instrumentation and % 65 in hybrid instrumentation. CONCLUSION Transpedicular screw instrumentation in severe IS is a safe and effective method in proper hands when flexibility of the curve evaluated accurately in preoperative period.

Isolated Adult Tillaux Fracture Associated With Volkmann Fracture-A Unique Combination of Injuries: Report of Two Cases and Review of the Literature.

Avulsion fractures of the anterior inferior tibiofibular ligament from its tibial attachment, Tillaux fractures, are usually seen in adolescents during the interval of the distal tibial epiphyseal closure. However, this pattern of fracture is rare in adult patients, because the ligaments will usually fail before the bone fails. Avulsion fracture of the posterior inferior tibiofibular ligament from its tibial attachment, Volkmann fracture, is the posterolateral counterpart of a similar injury. In the present study, the cases of 2 adult patients with simultaneous Tillaux and Volkmann fractures are reported and the mechanism of injury, diagnosis, and treatment discussed. This fracture pattern is extremely rare and, to the best of our knowledge, has not been previously reported.

Reliability of the mangled extremity severity score in combat-related upper and lower extremity injuries.

Background: Decision of limb salvage or amputation is generally aided with several trauma scoring systems such as the mangled extremity severity score (MESS). However, the reliability of the injury scores in the settling of open fractures due to explosives and missiles is challenging. Mortality and morbidity of the extremity trauma due to firearms are generally associated with time delay in revascularization, injury mechanism, anatomy of the injured site, associated injuries, age and the environmental circumstance. The purpose of the retrospective study was to evaluate the extent of extremity injuries due to ballistic missiles and to detect the reliability of mangled extremity severity score (MESS) in both upper and lower extremities. Materials and Methods: Between 2004 and 2014, 139 Gustillo Anderson Type III open fractures of both the upper and lower extremities were enrolled in the study. Data for patient age, fire arm type, transporting time from the field to the hospital (and the method), injury severity scores, MESS scores, fracture types, amputation levels, bone fixation methods and postoperative infections and complications retrieved from the two level-2 trauma centers data base. Sensitivity, specificity, positive and negative predictive values of the MESS were calculated to detect the ability in deciding amputation in the mangled limb. Results: Amputation was performed in 39 extremities and limb salvage attempted in 100 extremities. The mean followup time was 14.6 months (range 6–32 months). In the amputated group, the mean MESS scores for upper and lower extremity were 8.8 (range 6–11) and 9.24 (range 6–11), respectively. In the limb salvage group, the mean MESS scores for upper and lower extremities were 5.29 (range 4–7) and 5.19 (range 3–8), respectively. Sensitivity of MESS in upper and lower extremities were calculated as 80% and 79.4% and positive predictive values detected as 55.55% and 83.3%, respectively. Specificity of MESS score for upper and lower extremities was 84% and 86.6%; negative predictive values were calculated as 95.45% and 90.2%, respectively. Conclusion: MESS is not predictive in combat related extremity injuries especially if between a score of 6–8. Limb ischemia and presence or absence of shock can be used in initial decision-making for amputation.

A giant medial parameniscal cyst of the knee joint

A 34-year-old man presented with a painful large mass over the medial aspect of his left knee that enlarged during the last 6 months. The pain was increasing when standing after squatting and while descending the stairs. On physical examination, the lesion was firm and immobile and there was slight tenderness with palpation (figure 1A). Knee joint movements were normal without ligamentous instability, but McMurray test was painful in the medial meniscus. He could not remember any exact trauma. His medical history was unremarkable. Plain radiographs revealed only a faint soft tissue expansion at the level of the knee joint without any other bony lesion or deformity (figure 1B,C). MRI showed a large parameniscal cyst (50×15×42 mm) extending medially …

Bilateral fractures of the hook of the hamate: a bicycle handlebar injury.

A 38-year-old man presented with a history of bilateral ulnar-sided wrist pain that began after a traffic accident 1 month previously. He had been hit by a motor vehicle from the front while riding a bicycle and grasping the handlebars tightly. Immediately after the accident, he was brought to the nearest emergency department and bilateral wrist radiographs were taken. Standard wrist radiographs showed no abnormal findings; he was diagnosed as having a wrist sprain and treated with anti-inflammatory medications, rest, and ice. He attended our clinic to seek further help for ongoing symptoms. On physical examination, both wrists had normal appearances without any swelling or skin abrasions. There was tenderness over Guyon’s canal. The range of wrist movements was in the normal range, with slight pain. Neurovascular examination was normal. The initial wrist radiographs were reviewed but showed no abnormalities. Bilateral wrist magnetic resonance imaging (MRI) demonstrated bilateral fractures of the hooks of both hamate bones (Figure 1). Short-arm plaster casts were applied for 4 weeks, after which a gradual return to full activities was allowed. At the final follow-up 6 months after the initial injury, a repeat wrist MRI showed union of the fractures. The patient was free of pain and had returned to his previous level of activities, including work. Various mechanisms of injury have been proposed for fractures of the hook of the hamate. They are most often secondary to a direct blow produced by the handle of a golf club, baseball bat, or tennis racquet, or after a fall on an outstretched hand, striking the base of the hypothenar area (Scheufler et al., 2005; Stark et al., 1977). Furthermore, a fracture of the hook of the hamate may present as a stress fracture due to repetitive overload rather than a single traumatic event, and this may occur in those participating in racquet sports (Guha and Marynissen, 2002). In this case, the hook of hamate fractured when the patient grasped the bicycle handlebars. This mechanism of injury is similar to the mechanism of injury in holding a racquet, bat, or club. In one of the largest series of hook of hamate fractures that included 14 patients, four had had bicycle accidents (Scheufler et al., 2005). Sorene and Goodwin (2006) reported a case of bilateral nonunion of the hook of the hamate causing carpal tunnel syndrome, and this case was also the result of a bicycle accident. Although details about the circumstances of the accidents and probable mechanisms of injury are not available in previous reports, we were able to take a detailed history of the incident from the patient. He did not fall to the ground or sustain a crush injury to Figure 1. Axial T1-weighted MRI of both wrists showing bilateral fractures of the hook of the hamate (arrows).