[Correction of complex lower extremity deformities with the use of the Ilizarov-Taylor spatial frame]. / Kompleks alt ekstremite deformitelerinin Ilizarov-Taylor uzaysal çerçeve ile düzeltilmesi.

OBJECTIVES: We evaluated the effectiveness of the Taylor spatial frame (Smith & Nephew, Memphis, TN, USA) in the treatment of complex lower extremity deformities. METHODS: The Taylor spatial frame (TSF) was applied to 29 bone segments of 25 patients (12 females, 13 males; mean age 17 years). Indications for the TSF were congenital disorders (n=12), rickets (n=6), physeal injuries (n=4), stiff nonunions (n=3), malunions (n=3), and sequela from septic arthritis of the knee (n=1). Applications involved the tibia (n=15), femur (n=9), foot (n=4), and knee (n=1) with (n=24) or without (n=5) osteotomies. Following acute correction with the use of the TSF and internal osteosynthesis by plating or nailing, the fixator was removed in six cases. The chronic mode was used in six cases who underwent acute correction. The remaining deformities were gradually corrected using the "total residual mode". The follow-up period ranged from eight months to 42 months (mean 29 months). RESULTS: The mean duration of external fixator was 24.5 weeks (range 18 to 37 weeks) in 13 tibial and five femoral segments. In all cases, correction was applied until the mechanical axis reached normal limits. Complete consolidation was achieved in all osteotomized segments, including three cases of nonunion. A plantigrade foot was obtained in all foot deformities. Recurrence was seen in one case in which knee contracture and subluxation were treated with soft tissue distraction without osteotomy. CONCLUSION: The Taylor spatial frame is a safe and practical method with excellent results in the treatment of nonunions and deformities complicated especially by translation and rotation providing correct clinical data are derived and used.

[Epithelioid hemangioendothelioma of bone]. / Kemikte yerlesim gösteren epiteloid hemanjiyoendotelyoma.

Epithelioid hemangioendothelioma is a low-grade malignant tumor with a histologic appearance and clinical course between that of a hemangioma and angiosarcoma. It is rarely encountered in the bone. A 48-year-old woman was examined following trauma. A cystic lesion was noted on a plain radiograph of the left foot, destructing the diaphysis of the first metatarsal bone. Magnetic resonance imaging showed a solid intramedullary lesion involving a large part of the bone. Scintigraphic examination showed uptake in the diaphysis of the left tibia and the first metatarsal bone of the left foot. Histopathologic examination showed a neoplastic lesion consisting of atypical endothelial cells lining vascular structures or forming solid nests in a myxoid stroma. The tumor was immunoreactive for factor VIII, CD31, CD34, and vimentin. A diagnosis of epithelioid hemangioendothelioma was made and the patient underwent subtotal resection of the metatarsal bone with reconstruction of the fibula, and a wide resection of the tibial lesion. No recurrences or metastasis were observed during a four-year follow-up.

[Evaluation of vertebral fractures and associated injuries in adults]. / Eriskinlerdeki vertebra kiriklarinin ve eslik eden yaralanmalarin degerlendirilmesi.

OBJECTIVES: We evaluated vertebra fractures and associated injuries in adults to determine the profile of patients presenting with a trauma etiology. METHODS: The study included 372 patients (264 men, 108 women; mean age 30.4 years; range 18 to 65 years) who were treated for vertebra fractures from 1988 to 2003. Evaluations included demographic features of patients, trauma mechanisms, fracture levels and types, treatment modalities, and associated injuries. The types of fractures were assessed according to the Denis classification. RESULTS: The types of fractures were classified as follows: compression fractures (n=212, 57.0%), burst fractures (n=146, 39.3%), seat belt-induced fractures (n=8, 2.2%), and fracture-dislocations (n=6, 1.6%). Involvement was at one level in 290 patients (77.9%), two levels in 61 patients (16.4%), three levels in 15 patients (4.0%), and four levels in six patients (1.6%). The most common localization was the thoracolumbar spine (transition zone) with 275 fractures (57.2%). The causes of fractures were fall from height in 211 patients (56.7%), traffic accidents in 145 patients (39.0%), and direct trauma in 16 patients (4.3%). Associated fractures were detected in 110 patients (29.6%), the most common being calcaneus fractures in 35 patients (9.4%). Apart from orthopedic problems, 38 patients (10.2%) had other organ injuries and/or head trauma. Treatment was conservative in 302 patients (81.2%) and surgical in 70 patients (18.8%). CONCLUSION: Every patient presenting after a high-energy trauma should be regarded as having a vertebra fracture until proven otherwise. When a vertebra fracture is detected, investigation should be extended for involvement at other levels and associated injuries.

The role of a posteriorly positioned fibula in ankle sprain.

BACKGROUND: Specific anatomic variations of the ankle mortise may predispose people to ankle sprains. HYPOTHESIS: There is a correlation between a higher malleolar index (posteriorly positioned fibula) and incidence of ankle sprain. STUDY DESIGN: Prospective case control study. METHODS: We compared the malleolar index (transverse plane of the talus) on computerized axial tomographic images of 61 patients with ankle sprain with that of 101 normal controls. A positive number for the malleolar index meant that the lateral malleolus was posterior to the plane of the medial malleolus. A negative number meant that the lateral malleolus was actually anterior to the plane of the medial malleolus. RESULTS: The average malleolar index of the patients with ankle sprain was +11.5 degrees with a standard deviation of 7 degrees. Malleolar relationships varied from -6 degrees to +39 degrees, a range of 45 degrees. The average malleolar index in the control group was +5.85 degrees with a standard deviation of 4.9 degrees, which varied from -8 degrees to +16 degrees. However, there was no correlation between recurrence of sprains and malleolar index values. CONCLUSION: Patients with an ankle sprain were more likely to have a posteriorly positioned fibula, possibly predisposing them to ankle sprain.

The application of open intramedullary fixation in the treatment of pediatric radial and ulnar shaft fractures.

OBJECTIVES: This retrospective review evaluates the efficiency of standard intramedullary Kirschner wires for the treatment of unstable diaphyseal forearm fractures in children. DESIGN: Retrospective review. SETTING: Large teaching and research hospital in Turkey. PATIENTS: Thirty-one patients with diaphyseal forearm fractures were treated by surgical method between 1988 and 1998. The mean age was 12.3 years (range 7 to 17 years). The mean follow-up period was 4.2 years (1 to 6.2 years). INTERVENTION: The method of treatment of each forearm fracture was open reduction and intramedullary Kirschner wire fixation using a mini-incision. MAIN OUTCOME MEASUREMENTS: Fracture union, growth disturbance of the forearm, and complications were evaluated. RESULTS: Union was obtained in all cases except two (6.4 percent). No forearm inequality was observed. CONCLUSIONS: Intramedullary fixation is a useful technique for unstable shaft fractures of the forearm in children that can not be treated by closed manipulation.

Management of the neuromuscular foot deformities with the Ilizarov method.

Nine feet of eight patients with neurologic foot deformities caused from poliomyelitis, Charcot-Marie-Tooth disease, and traumatic nerve injury were treated with V-osteotomy and the Ilizarov method. A painless and plantigrade foot was obtained in all but one patient. A residual deformity occurred in this case because of the soft-tissue problems during the correction period. No major complication had been encountered by the latest follow-up at a mean of 42 months. The results of the current study indicate that the V-osteotomy and the Ilizarov method, while technically difficult, is an effective method for correcting neurologic foot deformities and obtaining a stable, plantigrade, painless foot, especially when complicated with other lower leg problems (i.e., leg length discrepancy, joint contractures).

Correcting and lengthening of metatarsal deformity with circular fixator by distraction osteotomy: a case of longitudinal epiphyseal bracket.

The condition known as longitudinal epiphyseal bracket or delta phalanx is a rare congenital anomaly that affects the tubular bones of hand or foot. Metatarsal epiphyseal bracket restrains longitudinal growth, causing progressive deformity and resulting in a short, broad metatarsal and a medially deviated metatarsophalangeal joint and hallux magnus. Although there are some case series describing metatarsal lengthening with the unilateral fixator in the literature, we could not find any case that combines both metatarsal lengthening and deformity correction with the circular external fixator. Gradual lengthening and deformity correction without bone grafting and soft-tissue modification were carried out in a case with bilateral longitudinal epiphyseal bracket of the first metatarsals of the foot. A literature review and treatment method for epiphyseal bracket in a 9-year-old boy is presented. Excellent clinical, and functional results were obtained with circular and semicircular fixators.

Aneurysmal bone cyst in the hamate.

Aneurysmal bone cysts (ABCs) show a predilection for the metaphysis of the long bones and the vertebrae and seldom involve the carpal bones. We present a case of an ABC in the left hamate of an 18-year-old man. Curettage and bone grafting were performed, and, because destruction of the cortex was extensive, the hamate was excised. At 3-year follow-up, the wrist was stable.

[Long-term results of olecranon fractures treated with tension-band wiring technique]. / Olekranon kirikli olgularda gergi bandi tipi osteosentez tekniginin geç dönem sonuçlari.

OBJECTIVES: We evaluated the long-term results of olecranon fractures treated with tension-band wiring (Zuggurtung) technique. METHODS: The study included 41 patients (28 males, 13 females; mean age 48 years; range 20 to 85 years) who underwent tension-band wiring osteosynthesis for olecranon fractures. The involved side was the right in 25 patients, and the left in 16 patients. Associated bone and soft-tissue injuries were detected in 16 patients. There were open fractures of Gustilo type 1 in two patients, and type 2 in one patient. The fractures were classified according to the Schatzker's system, and the results according to the Murphy's system. The mean follow-up was 46.7 months (range 12 to 141 months). RESULTS: Complete union was obtained in all fractures. According to the Murphy's system, the results were very good and good in 31 patients (75.6%), fair in five patients (12.2%), and poor in five patients (12.2%). It was obvious that fracture type and accompanying trauma had influenced the treatment results. Of open fractures, the results were poor in two patients, and fair in one patient. Of 10 patients with a fair or poor outcome, eight patients had accompanying bone injuries. Complications included migration of the K-wire in two patients, and irritation related to K-wires in four patients. CONCLUSION: Osteosynthesis with tension-band wiring technique in olecranon fractures offers considerable advantages: a stable fixation is obtained at a very low cost, development of joint stiffness is avoided by early elbow range of motion, and minimal joint stiffness seen in the long term does not present as a functional disability.

[Treatment of intertrochanteric fractures of the femur with Ender nails in patients over the age of 65 years]. / Altmis bes yas üzerindeki hastalarin femur intertrokanterik kiriklarinda Ender çivisi ile osteosentez.

OBJECTIVES: We evaluated the results of treatment with Ender nails in intertrochanteric fractures of the femur in patients exceeding the age of 65 years. METHODS: Thirty-three patients (18 women, 15 men; mean age 78 years; range 65 to 98 years) were treated with Ender nails for non-pathological fractures of the intertrochanteric part of the femur. The right hips were involved in 17 patients and the left in 15 patients. One patient had bilateral involvement. Serious complicating diseases existed including cardiovascular disease (n=12), pulmonary disease (n=11), and others (n=10) such as diabetes mellitus. According to the Evans-Jensen classification, there were 14 type 1, five type 2, four type 3, four type 4, and seven type 5 fractures. The mean follow-up was 20 months (range 5 to 78 months). RESULTS: The mean length of hospital stay was 15 days (range 9 to 18 days). Mortality was encountered in 10 patients (30.3%) within the first postoperative year, two of whom (6%) died during hospitalization. Twelve patients were alive on final follow-ups, of these eight patients were ambulatory without any significant problem. Postoperatively, one patient developed electrolyte imbalance, and another had urinary infection. Due to migration problems, one of the three nails had to be removed in the early period in one patient, and all nails in five patients after the union was obtained. Union was obtained in all patients within a mean of eight weeks (range 6 to 18 weeks). CONCLUSION: Ender nailing may be appropriate in stable, non-displaced intertrochanteric fractures in the elderly, as it is associated with lower mortality in the early period.

[Traumatic femoral diaphyseal fracture and a bent intramedullary nail in a case with a completely healed femoral diaphyseal fracture]. / Kaynamis opere femur diafiz kiriginda travmatik femur diafiz kirigi ve Küntscher çivisi bükülmesi: Olgu sunumu.

Bending of a Kuntscher nail which had been used in the treatment of a prior femoral diaphyseal fracture was encountered in a 37-year-old male patient who was admitted to hospital for a deformity in his left thigh caused in a car accident. The nail was extracted and osteosynthesis was performed via an intramedullary locked nail. Union was obtained in the fourth postoperative month without any complications.

[Results of excision of the radial head in comminuted fractures]. / Radius basi parçali kiriklarinda eksizyon ve sonuçlari.

OBJECTIVES: To evaluate the results of radial head excision in the treatment of comminuted radial head fractures. METHODS: The study included 20 patients (14 men, 6 women; mean age 34 years; range 21 to 55 years) who underwent radial head excision for comminuted, closed fractures. Sixteen patients had Mason type 3 and four patients had type 4 fractures. Surgery was performed at a mean of eight days after trauma (range 1 to 30 days). Patients were assessed with regard to whether they were able to return their former activities and work, and whether they had pain, limitation, loss of strength, and instability. The results were evaluated by the Radin and Riseborough's classification. The mean follow-up period was seven years (range 2 to 12 years). RESULTS: Sixteen patients (80%) re-gained their previous activities or work. Nine patients became asymptomatic. Five patients complained of loss of strength in the arm. Pain associated with weight bearing was observed in two patients in the wrist and elbow, respectively, and in both in two patients. Two patients had limitation of more than 30 degrees in at least one of extension, flexion, supination, or pronation. Five patients had mediolateral instability. The mean elbow flexion was 125 degrees (range 100 to 140 degrees). Proximal migration of the radius was detected in five patients (1 mm), two patients (3 mm), and in three patients (5 mm). According to the Radin and Riseboroughs classification, nine (45%), seven (35%), and four (20%) patients had good, fair, and poor results, respectively. CONCLUSION: Despite its relevance in elbow kinematics, our results seem to justify excision of the radial head in Mason type 3 comminuted radial head fractures where internal fixation presents severe difficulties.

[Surgical treatment of tibial plateau fractures]. / Tibia plato kiriklarinin cerrahi tedavisi.

OBJECTIVES: This study was designed to determine surgical indications in tibial plateau fractures and to evaluate the effect of surgical treatment on the outcome. METHODS: Forty patients (12 women, 28 men; mean age 39 years; range 18 to 75 years) underwent surgical treatment for 41 tibial plateau fractures. Final evaluations included 37 patients (38 knees). Fractures were classified according to the Schatzker's system, being type 1 (11 fractures), type 2 (11), type 3 (1), type 4 (6), type 5 (5), and type 6 (7). The indications for surgery were defined as the presence of depression, displacement, and instability being greater than 4 mm, 10 mm, and 10 degrees, respectively. The mean follow-up was 35.8 months (range 6 to 107 months). RESULTS: Clinical results were assessed using the Rasmussen criteria. Successful results accounted for 86.8%. The results were excellent, good, moderate, and poor in 14 knees (36.8%), 19 knees (50%), three knees (7.9%), and 2 knees (5.3%), respectively. Postoperative complications included deep (2 patients) and superficial (2 patients) infections, malunion in two patients, arthrofibrosis in three patients, and myositis ossificans in one patient. Radiologic evaluations were based on the Resnic and Niwayama's system, which showed successful outcome in 73.6%. The results were excellent in 11 knees (28.9%), good in 17 knees (44.7%), moderate in six knees (15.8%), and fair in four knees (10.6%). CONCLUSION: In order to achieve satisfactory results in tibial plateau fractures that meet surgical indications including depression (>4 mm), displacement (>10 mm), and instability (>10 degrees), special attention should be given to obtain a rigid osteosynthesis with early mobilization and to avoid weight-bearing until bone healing is completed.

[Plate fixation of closed femoral shaft fractures in adolescents]. / Adölesan kapali femur cisim kiriklarinin tedavisinde plak ve vida ile osteosentez.

OBJECTIVES: This study was designed to evaluate the results, advantages, and disadvantages of plate fixation of closed femoral shaft fractures in adolescents between the ages of 11 and 15 years. METHODS: The study included 35 adolescents (26 males, 9 females; mean age 13.4 years) who were treated by plate fixation for closed femoral shaft fractures and had an adequate follow-up. The fractures were bilateral in two patients, on the left in 17 patients (48%), and on the right in 16 patients (45%). Traffic accidents were the most frequent etiology (57%). Nineteen patients presented with head injuries and/or multiple fractures. The mean follow-up was 34.9 months (range 22 to 156 months). RESULTS: All fractures healed in a mean of 10 weeks (range 6 to 16 weeks). No plate break or refractures occurred. Two patients had a loss of 20 degrees in knee flexion. Atrophy of the quadriceps muscle was observed in nine patients. Evaluations with the use of scanogram, orthorontgenogram, plain radiographs, and clinical examination showed an average overgrowth of 1.2 cm (range 0.4 to 1.6 cm). CONCLUSION: Despite some disadvantages, plate fixation seems to be an alternative method in the treatment of adolescent femoral fractures, enabling an anatomical reduction and stable internal fixation.

Lengthening over a retrograde nail using 3 Schanz pins.

The technique of lengthening over an antegrade nail is used widely for distraction osteogenesis of the femur. Most reported complications of this technique are related to Schanz pins. We hypothesized that reducing the number of Schanz pins would enable successful distraction with fewer complications. To this purpose, we describe a new technique for lengthening over a retrograde nail using only 1 proximal and 2 distal Schanz pins.

Calculating the mounting parameters for Taylor Spatial Frame correction using computed tomography.

The Taylor Spatial Frame uses a computer program-based six-axis deformity analysis. However, there is often a residual deformity after the initial correction, especially in deformities with a rotational component. This problem can be resolved by recalculating the parameters and inputting all new deformity and mounting parameters. However, this may necessitate repeated x-rays and delay treatment. We believe that error in the mounting parameters is the main reason for most residual deformities. To prevent these problems, we describe a new calculation technique for determining the mounting parameters that uses computed tomography. This technique is especially advantageous for deformities with a rotational component. Using this technique, exact calculation of the mounting parameters is possible and the residual deformity and number of repeated x-rays can be minimized. This new technique is an alternative method to accurately calculating the mounting parameters.

Prevalence of untreated hip dislocation in Turkish children aged 6 months to 14 years.

OBJECTIVE: In this study, our aim was to determine the prevalence of untreated hip dislocation and subluxation in Turkey. METHODS: Pelvic radiographs of 4,947 children, aged between 6 months and 14 years, taken for non-orthopedic purposes were requested from 23 provinces around the country. 3,723 radiographs met the study criteria and were evaluated. Dislocated and subluxated hips were identified according to the relationship of femoral head using Perkins line and quadrants. RESULTS: Thirty-five hips in 22 children were found to be dislocated or subluxated. The prevalence rate was calculated as 5.9% CONCLUSION: Despite appearing to have decreased when compared to limited regional prevalence studies, hip dislocation and subluxation prevalence is still unacceptably high. More extensile work should be done to avoid external factors in the etiology of developmental dysplasia of the hip and to organize screening programs in newborns.

Neuromuscular deformity: treatment with external fixation.

A multiplanar foot deformity is defined by the presence of more than one deformity affecting the foot. These deformities may develop in any plane, including the frontal, sagittal, or transverse planes. This article focuses on the treatment of multiplanar neuromuscular foot deformities with external fixation, reviewing the indications, preoperative planning, techniques, and complications.

The new intramedullary cable bone transport technique.

Traditional segment transport methods pose major soft tissue and bone problems related to the pin or K wire that fixes the transported bone segment through the soft tissue, especially excursion of the K wire. We designed the cable bone transport technique to prevent these problems and to increase patient comfort. Thirteen patients with bone defects (11 in the tibia and 2 in the femur) were treated successfully with the new method. Because the transported segment is not fixed externally in the cable bone transport method, docking site troubles, such as soft tissue invagination and malalignment, and skin problems due to excursion of the K wire are prevented, which in turn reduces other difficulties that might arise from alternative procedures.

Conservative treatment of fractures of the thoracolumbar spine.

We reviewed 48 patients with thoracolumbar fractures treated conservatively between 1988 and 1999. The average follow-up was 77.5 (31-137) months and average patient age (23 women, 25 men) was 46 (18-76) years. Twenty-nine patients suffered a fall from a height and 13 patients were injured in traffic accidents. Thirty-two patients had compression-type fractures and 16 burst-type fractures. There were no neurological deficits. Twenty-nine patients were treated by orthosis, 13 by body cast and six by bed rest. In addition to pain and functional scoring, we measured a number of radiographic parameters at the time of admission and at latest follow-up and compared the values. In patients with compression fractures there were significant changes in scoliosis angle and wedging index (p<0.05). The mean pain score was 1.66 and mean functional score 1.03. In patients with burst fractures, vertebral index, wedging index and height loss increased after treatment (p<0.05). The mean pain score was 1.26 and functional score 0.93. Compression fractures with kyphosis angle <30 degrees are supposed to be stable and can be treated conservatively. If the kyphosis angle is more than 30 degrees, magnetic resonance imaging (MRI) should be performed, and if the posterior ligamentous complex is damaged, surgery should be considered. In burst fractures, MRI should always be performed and conservative treatment should only be considered if there is no neurological deficit and the ligaments are intact.