Calcaneal Apophyseal Fracture Followed by Subtalar Joint Instability in a Young Female: A Case Report.

Calcaneal apophyseal fractures are usually considered sport-related injuries. Previous repetitive microtrauma has been proposed as a predisposing factor for such injuries. However, unlike previously reported cases, in our patient, the fracture resulted from acute trauma after stepping on uneven ground. Although the first treatment option for such cases is closed reduction, most cases will require surgical treatment. Furthermore, lesions accompanying this injury have not been sufficiently considered. We report the case of a 9-year-old female with a calcaneal apophyseal fracture treated by fixation of the avulsed proximal part of the apophysis using Kirschner wires and a cerclage wire. However, subsequently, instability developed in the subtalar joint. Fifteen months after the first osteosynthesis, surgery was performed to fixate the subtalar joint and secure the insertion region of the tendo calcaneus. After the first surgery, subtalar joint instability might have developed because of simultaneous disruption of the subtalar ligaments at the initial injury. Subsequently, the instability could have caused failure of the first fixation. Debridement and fixation of the subtalar joint in the second surgery provided a stable subtalar joint. A calcaneal apophyseal fracture might be associated with additional injuries at the hindfoot. Before treating these cases, other injuries that might be obscured by the more apparent injuries should be considered. Accompanying soft tissue injuries, such as subtalar joint ligament lesions, can be revealed with magnetic resonance imaging evaluation. To the best of our knowledge, this is the first report of an apophyseal fracture of the calcaneus followed by subtalar joint instability.

Drilling through anteromedial portal with a femoral aiming device ensures a sufficient length and a proper graft position, and prevents posterior wall breakage during anterior cruciate ligament reconstruction.

OBJECTIVE: The aim of this study was to evaluate the characteristics of the femoral tunnel (FT) which was drilled through the AM portal by using a femoral aimer device and AP stability of the knee. METHODS: Thirty-eight patients, with the mean age 29.6 (range: 20-43) years, were evaluated after ACL reconstruction. The mean follow-up time was 31.9 (range: 16-57) months. The FT was drilled using a femoral aimer with different offset according to the graft size measured, through the AM portal. The semitendinous and gracilis tendon autograft was used for reconstruction. The angles of FT and the exit point on the lateral condyle were measured on AP views of the knee. AP stability of the knee was measured with the KT-2000. RESULTS: The mean angle of FT was 46.5° (± 8.4°), on the AP view. The mean distance between the exit point of FT and the most distal end of the femoral condyles was 46.7 (± 4.9) mm. The mean FT length was 36.1 (± 3.1) mm. The mean difference of anterior translation compared to the intact knee was 1.9 (± 1.6) mm. Except the three patients, with "one positive" pivot shift test, in the remaining 35 knees stability was equal to the healthy knee. CONCLUSIONS: Femoral drilling by using a femoral aimer device through AM portal provided long enough FT for safe graft fixation and appropriate coronal plan obliquity. The exit point was far proximal from the insertion site of the popliteus tendon and lateral collateral ligament. Furthermore, the AM portal technique significantly improved AP stability of the knee.

Pathogens in Pediatric Septic Arthritis: A Multi-Center Study in Turkiye (PEDSART Study).

OBJECTIVES: Septic arthritis (SA) is a serious bacterial infection that must be treated efficiently and timely. The large number of culture-negative cases makes local epidemiological data important. Accordingly, this study aimed to evaluate the etiology, clinical characteristics, and therapeutic approach of SA in children in Turkiye, emphasizing the role of real-time polymerase chain reaction (PCR) techniques in the diagnosis. METHODS: In this multi-center, prospective study, children hospitalized due to SA between February 2018 and July 2020 in 23 hospitals in 14 cities in Turkiye were included. Clinical, demographic, laboratory, and radiological findings were assessed, and real-time PCR was performed using synovial fluid samples. RESULTS: Seventy-five children aged between 3 and 204 months diagnosed with acute SA were enrolled. Joint pain was the main complaint at admission, and the most commonly involved joints were the knees in 58 patients (77.4%). The combination of synovial fluid culture and real-time PCR detected causative bacteria in 33 patients (44%). In 14 (18.7%) patients, the etiological agent was demonstrated using only PCR. The most commonly isolated etiologic agent was Staphylococcus aureus, which was detected in 22 (29.3%) patients, while Streptococcus pyogenes was found in 4 (5.3%) patients and Kingella kingae in 3 (4%) patients. Streptococcus pyogenes and Kingella kingae were detected using only PCR. Most patients (81.3%) received combination therapy with multiple agents, and the most commonly used combination was glycopeptides plus third-generation cephalosporin. CONCLUSIONS: Staphylococcus aureus is the main pathogen in pediatric SA, and with the use of advanced diagnostic approaches, such as real-time PCR, the chance of diagnosis increases, especially in cases due to Kingella kingae and Streptococcus pyogenes.

Factors Affecting the Clinical Outcomes of Surgically Treated Ankle Fractures Associated with the Posterior Malleolar Fragment.

BACKGROUND: This study was performed to determine the factors that influence the clinical outcomes of surgically treated ankle fractures associated with the posterior malleolus (PM). METHODS: We evaluated 42 fractures of 42 patients. Posterior malleolus fracture size was calculated using computed tomography. Posterior malleolar fractures with a size less than 10% were left nonfixated. The decision for larger fragments was performed using fluoroscopy following the fixation of other components. If the joint was found to be congruent, the PM was left nonfixated. Otherwise, the PM was reduced and fixated. Clinical outcomes were evaluated based on Weber, Freiburg, and American Orthopaedic Foot and Ankle Society scores. Ankle osteoarthritis was determined according to the Canadian Orthopaedic Foot and Ankle Society classification. The effect of PM fixation, age, PM fragment size, waiting period before surgery, presence of ankle dislocation, and number of injured malleoli on clinical outcomes were assessed. Statistical significance was set at a value of P < .05. RESULTS: The mean patients age was 48.5 ± 14.9 years (range, 20-84 years) and the mean follow-up was 23.7 ± 8.6 months (range, 12-56 months). Fixation of the PM was performed solely in 12 patients. Postoperative displacement of the PM and articular step were less than 2 mm in all fractures. Statistically significant worse outcomes were demonstrated based on functional scores in the patients with a PM size greater than or equal to 25% (P = .042, P = .038, and P = .048, respectively) and in patients aged 60 years or older (P = .005, P = .007, and P = .018, respectively). However, there was no significant difference between functional scores and the other factors. Ankle osteoarthritis was observed at a higher rate in patients with PM size greater than or equal to 25% and in patients aged 60 years or older. CONCLUSIONS: Clinical outcomes of the patients are mainly influenced by the patient's age and PM fragment size. However, if the tibiotalar joint is congruent, comparable results can be obtained in PM fixated or nonfixated patients.

Comparison of single and double dorsal wires in the extension block technique for mallet fractures: Retrospective observational study.

ABSTRACT: Mallet fractures are avulsion fractures of the extensor tendon from the distal phalanx base and often occur due to sudden flexion or axial loading. In this study, we aimed to compare the clinical and radiological results of patients treated with single and double dorsal wires from the dorsal in the extension block method.Patients to whom a single wire from dorsal was applied were assigned to Group 1 (n: 22), and those to whom double wires were applied were assigned to Group 2 (n: 23). Surgical treatment was decided for patients with more than 1/3 of the fracture fragment containing the joint surface and volar subluxation. The range of motion of the distal interphalangeal (DIP) joint was measured with a goniometer. The displacement of the fragment was measured before and after surgery on lateral radiographs. The presence of bridging callus formation on anterior-posterior and lateral radiographs was evaluated for a union.There were 30 male (66.7%) and 15 (33.3%) female patients. The mean age of the patients was 32 years. Radiographic union was obtained in all patients. Pseudoarthrosis was not observed in any patient. The Crawford score was excellent in 13 (28.9%) cases, the score was good in 18 (40%) cases, the scores were moderate in 13 (28.9%) cases, and the score was poor in 1 case (2.2%). There were no complications in 35 (77.8%) cases, dorsal bump complications occurred in 9 cases (20%), and osteoarthritis and dorsal bump complications occurred in 1 (2.2%) case. We did not observe nail deformity, skin necrosis, infection, or fingertip sensitivity. We found similar functional and clinical results between the groups.We recommend using single dorsal wire, as using double dorsal wires requires extra operation time, effort, and fluoroscopy.

Changes in prefrontal cortex activation with exercise in knee osteoarthritis patients with chronic pain: An fNIRS study.

The role of exercise on pain modulatory mechanism of the prefrontal areas is not clear. We aimed to determine the effects of exercise on functional activity of the prefrontal cortex in patients with knee osteoarthritis (OA) with chronic pain and to assess the relationships between changes in clinical variables and cortical hemodynamics with exercise via functional near-infrared spectroscopy (fNIRS). Fifteen patients with knee OA with chronic pain were included. All participants attended an exercise program 3 times a week for 6 weeks. Pain during activity was assessed by visual analogue scale (VAS). Pain catastrophization, kinesiophobia and functionality were also measured. Brain hemodynamic activity was assessed with a 47-channel fNIRS system before and after the exercise. Pain, pain catastrophization, kinesiophobia and functionality scores significantly improved (p < 0.05) while functional activity of the dorsolateral prefrontal cortex (DLPFC) during painful stimuli was significantly reduced after exercise program (p < 0.05). Change in cortical hemodynamic activity within the DLPFC was significantly correlated with change in pain perception (R = 0.54, p < 0.05) and pain catastrophization scores (R = 0.44, p < 0.05). Exercise resulted in improvements in clinical assessments of pain severity and pain catastrophization which was accompanied by alterations in prefrontal cortex activation. We provided evidence about the pain modulatory effects of exercise at cortical level which is correlated with clinical improvements in patients with chronic pain. We demonstrate the feasibility and potential of fNIRS methodology for i) elucidating the neural mechanisms underlying chronic and stimulus evoked pain, and ii) exploring the effect of treatment methods on brain functionality.

Effects of additional action observation to an exercise program in patients with chronic pain due to knee osteoarthritis: A randomized-controlled trial.

BACKGROUND: Knee osteoarthritis (OA) leads to pain, stiffness, and functional impairment and eventually decreased level of the quality of life. Although several treatment methods have been used to achieve pain relief, patients still complain of pain. OBJECTIVE: The aim of this study was to investigate the effects of the addition of action observation therapy to an exercise program on pain severity, pressure pain threshold, kinesiphobia functionality, and pain catastrophization in knee OA patients with chronic pain. METHODS: This prospective, randomized-controlled, superiority trial included a total of 36 patients with knee OA. The patients were randomly divided into two groups as the treatment group (n = 18) receiving action observation therapy in addition to exercise and control group (n = 18) receiving exercise alone. The interventions were performed three times weekly for six weeks. The primary outcomes were pain and pressure pain threshold. Secondary outcomes were kinesiphobia, functionality, and pain catastrophization. All participants were assessed at baseline (pre-intervention) and after the six-week treatment (post-intervention). RESULTS: There was no significant difference in the primary and secondary outcome measures before and after the intervention between the groups (p > 0.05). Both groups showed a significant improvement in all outcome measures after the intervention (p < 0.01). CONCLUSION: Our study results suggest that action observation therapy in addition to an exercise program does not contribute any additional benefits to pain, pressure pain threshold, kinesiophobia, pain catastrophization, and functionality in knee OA patients with chronic pain. Nonetheless, further large-scale, long-term, prospective studies are needed to gain a better understanding on this subject.

How are clinical outcomes related to the deviation severity of the tibiofemoral mechanical axis on coronal plane following knee arthroplasty?

OBJECTIVE: To analyze the effect of tibiofemoral mechanical axis (TFMA) deviation severity on clinical outcomes after total knee arthroplasty (TKA). METHODS: We retrospectively reviewed the patients who underwent primary TKA between January 2002 and December 2010. After applying inclusion/exclusion criteria, we evaluated 70 knees of 51 patients. The mean ± SD follow-up period was 7.08 ± 1.34 years. The knees were divided into 3 groups based on TFMAs. The first group, identified as "well aligned," included the TFMAs that were neutral within 3° (0° ± 3°) of alignment. The second group, identified as "outliers 1," included the slightly deviated TFMAs (-3° to -6° valgus and +3° to +6° varus). The third group, identified as "outliers 2," included the severely deviated TFMAs of more than 6° from neutral alignment (<-6° valgus and > + 6° varus). The clinical outcomes of each group were compared by evaluating the Oxford Knee Score (OKS), visual analog scale (VAS), and Short Form-36 physical component summary (SF-36 PCS) and mental component summary (SF-36 MCS) scores. RESULTS: We found that OKS, SF-36 PCS, and SF-36 MCS were nearly the same in the well-aligned and outliers 1 groups but worse in the outliers 2 group. VAS scores were nearly the same in all groups. (p > 0.05). CONCLUSION: Function scores were impaired when the TFMA deviated more than 6° from neutral. However, the differences in clinical outcomes between well-aligned knees and those of outliers were not found to be statistically significant in the medium term.

[Childhood injuries, their etiologies, and preventive measures]. / Cocuk yaralanmalari, nedenleri ve önlemler.

OBJECTIVES: The purpose of this study was to evaluate social, economical, and cultural factors of childhood injuries and to assess preventive measures. METHODS: The study included 120 children (75 boys, 45 girls; mean age 8.3 years; range 0 to 14 years) who presented to the emergency department due to trauma from September to December 2007. Information was gathered from the patients or parents on the following: age, number of siblings; time, etiology, place, and type of trauma; type and time of transportation, educational and sociocultural level of the parents, and whether the patient had a similar injury before. RESULTS: About one-tenth (10.8%) of the patients were admitted and treated. Twenty patients (16.7%) had at least one similar injury previously. Most of the events were household injuries (n=42, 35%). The highest number of injuries occurred at the ages of 7, 8, and 10 years, and the number of injuries remained high from 12 to 14 years of age. The most frequent site of injury was the elbow during the first six years of age, the wrist and the hand at ages 7 to 11 years, and the wrist from 12 to 14 years of age. The great majority of the mothers were housewives (86.7%). Occupation and educational status of the mother, and the number of siblings were not related with recurrent childhood injuries (p>0.05). CONCLUSION: This study provided helpful information on the characteristics of childhood trauma. Programs targeting to increase the awareness on pertinent risk behaviors and to promote educational efforts concerning the risks and preventive measures will be of great help in preventing childhood injuries, in particular at the beginning of school life (age 7) and adolescence (age 12), at which time child injuries show culmination.

[Long-term results of extensive surgical dissection in the treatment of congenital clubfoot]. / Dogustan çarpik ayak tedavisinde genis cerrahi diseksiyonun uzun dönem sonuçlari.

OBJECTIVES: We evaluated the long-term functional and radiographic results of patients who underwent extensive soft tissue dissection for the treatment of congenital clubfoot. METHODS: We retrospectively evaluated 47 feet of 30 patients (6 girls, 24 boys; mean age 9.8 months) who underwent extensive surgical dissection for congenital clubfoot. Involvement was bilateral in 17 patients. Surgical dissection included complete subtalar release (CSTR) in 35 feet, and posteromedial release (PMR) in 12 feet. The mean age was 9.6 months (range 6 to 23 months) in CSTR-, and 10.6 months (range 5 to 23 months) in PMR-treated patients. The patients were assessed with the Laaveg-Ponseti functional score, foot bimalleolar angle, and other radiographic measurements. The mean follow-up was 117.3 months (106.6 months in the CSTR, and 150.6 months in the PMR group). RESULTS: Functional results were excellent in 24 feet, good in 12 feet, fair in six feet, and poor in five feet. All the poor results were seen in the CSTR group. Of these five feet, two developed recurrences, two had both pes cavus and metatarsus adductus deformities, and one had pes cavus deformity. Considering the foot bimalleolar angle, 83.4% of PMR-treated feet, and 85.7% of CSTR-treated feet were rated as type 1 or 2. Functional scores were significantly correlated with the foot bimalleolar angle, talus-first metatarsus angle on anteroposterior and lateral radiographs, and with the talocalcaneal angle on anteroposterior radiographs (p<0.05). There were no significant differences between the two surgical procedures with respect to functional scores and radiographic measurements (p>0.05). CONCLUSION: Extensive surgical dissection enables simultaneous correction of all components of deformity and provides satisfactory results not only in the short-term but also in the long-term follow-up.

Dysplasia epiphysealis hemimelica: two cases in two different regional expression.

Dysplasia epiphysealis hemimelica most commonly presents as an overgrowth of the epiphysis in the lower limb. We report two cases, one a classical form involving the lower limb, and the other in a relatively rarer location in the wrist. Both cases were treated surgically by excision of the masses. We recommend excision of symptomatic intra-articular lesions by using MRI, which provides additional information concerning physeal line and extension of the mass, to prevent the development of angulation and to keep the range of motion.

Intramedullary K-wire fixation of pediatric forearm fractures and effects on the wrist.

This retrospective study evaluated the results of intramedullary Kirschner wire fixation in pediatric forearm fractures and the effects on the wrist. Twenty-seven patients with forearm fractures managed by limited open reduction and intramedullary K-wire fixation were included in this study. Differences in ulnar variance were examined on wrist radiographs. Average ulnar variance was -3.23 +/- 2.14 mm on the operated wrist and -2.30 +/- 2.06 mm on the contralateral wrist (P < .05).

[The effect of surgical exposure on the clinic outcomes of supracondylar humerus fractures in children]. / Cocuk suprakondiler humerus kiriklarinda cerrahi yaklasimin sonuca etkisi.

BACKGROUND: The clinic outcomes of supracondylar humerus fractures in children treated with open reduction and internal fixation by using two different surgical exposures were studied. METHODS: The clinic outcomes of seventeen and ten patients to whom lateral (LA) and posterior (PA) approaches were used respectively, were evaluated according to the Flynn's criteria. All fractures were extension type and classified as type II and III according to Gartland's classification. Left arm was broken in nineteen children and right arm in eight. The mean age was 8.5 years (range 3-13 years) and mean follow up was 19.4 months (range 8-50). RESULTS: Four (23.52%) of the seventeen patients with LA and two (20%) of the ten patients with PA suffered from a loss in the range of motion (ROM) of the elbow more than 10 degrees (p>0.05). Mean operation time was 53.14+/-18.11 minutes in the patients used LA and 68.54+/-17.67 minutes in the patients with PA. Satisfactory results were obtained in thirteen of the seventeen patients (76.47%) in the group with LA and in eight of the ten patients (80%) in the group with PA. CONCLUSION: It is concluded that in the open reduction of childhood supracondylar fractures of the humerus, LA and PA approaches without dividing triceps muscle do equally affect the ROM of the elbow. Although PA decreases the risk of ulnar nerve injury with Kirschner wire, it prolongs the operation time.

Outcome of Internal Fixation and Corticocancellous Grafting of Symphysis Pubis Diastasis Which Developed after Malunion of Pubic Rami Fracture.

We report a case of pubic symphysis diastasis, which was initially asymptomatic; however, it became symptomatic with urinary incontinence during pregnancy. The patient was treated with open reduction and internal fixation of the symphysis pubis. A corticocancellous autograft was used for filling the gap which remained despite bilateral compression of the iliac bones. We obtained satisfactory outcome in terms of symptoms at the 3 years' follow-up; however, there was instability findings in the X-rays with broken screws. We conclude that asymptomatic pubic symphysis diastasis might be symptomatic after additional trauma (such as pregnancy) in the following days, if it was unstable in the very beginning of injury. Fixation of old pubic symphysis diastasis with reconstruction plate by filling the gap by using corticocancellous autograft, might not prevent ultimate implant failure if the symphysis pubis diastasis is part of an unstable pelvic fracture in the very beginning.

Determination of the hip rotation centre from landmarks in pelvic radiograph.

OBJECTIVE: The hip rotation centre (HRC) is an important reference point in cases of total hip arthroplasty (THA). The aim of this study is to investigate the reference points in the Turkish population that enable the identification of the HRC in standard pelvic radiographs. METHODS: The pelvic radiographs of 50 women and 50 men were examined. The mean age was 46.2 (range; 18-91). Patients with deformity of the hip joint and non-standard pelvic radiograph due to hip flexion contracture were excluded from the study. The pelvic height (PH), the distance between the HRC and teardrop (HRC-Td), and the HRC and the line tangent tuber ischiadicums (HRC-TI) were measured. The ratio of HRC-Td and HRC-TI to PH were calculated. The first is called "the horizontal-HRC ratio" and the second, "the vertical-HRC ratio". RESULTS: Mean PH was 239 (±13.58) mm in males and 225 (±12.52) in females (p < 0.0001). The distances of HRC-TI were 71 (±6.35) and 65 (±6.72) mm (p < 0.0001) and the distance of HRC-Td were 34 (±3.73) and 30 (±4.05) mm (p = 0.0007), respectively. The vertical-HRC ratios were 30.01% (±2.05) for males, 29.10% (±2.35) for females, the horizontal-HRC ratio, 14.25% (±1.42) and 13.69% (±1.38), respectively (p > 0.05). CONCLUSION: Although the quantitative values obtained in the present study differ between the genders, the ratios ("vertical-HRC" and "horizontal-HRC") are comparable in both sexes. The results show that these proposed ratios can be used in THA planning, regardless of gender in the Turkish population LEVEL OF EVIDENCE: Level IV, diagnostic study.

[Preservation of the foot in a five-year-old child with bilateral congenital deficiency of the tibia]. / Iki tarafli dogustan tibia gelisme eksikligi olan 5 yasindaki bir çocukta ayagi koruyucu yaklasim.

Congenital tibial deficiency is a rare anomaly causing shortening and varus deformity of the lower extremity. Recent limb lengthening and foot repositioning techniques enable functional results with preservation of the foot. We present a five-year-old boy with bilateral congenital tibial deficiency of type 2 according to the Jones classification, who was treated with tibia-fibular fusion without Syme amputation. His ambulation depended on crawling. Radiographic examination showed a normally developed fibula with thickening in the distal portion, and only proximal tibia with absence of the distal part. He also had bilateral stiff equinovarus deformity. In a series of operations, he underwent bilateral tibia-fibular fusion and fibular osteotomy, subtalar arthrodesis and metatarsal osteotomy in the right foot, and subtalar arthrodesis in the left foot. At the end of a six-year treatment and follow-up, walking was achieved despite some degree of limping.

[Evaluation of complications of femoral neck fractures in children operated on at least 24 hours after initial trauma]. / Femur boynu kirigi nedeniyle ilk 24 saatten sonra ameliyat edilen çocuklarda gelisen komplikasyonlarin degerlendirilmesi.

OBJECTIVES: We evaluated complications and the factors affecting the development of avascular necrosis of the femoral head in children who underwent surgery for femoral neck fractures after at least a 24-hour delay. METHODS: We reviewed the results of 22 children (11 boys, 11 girls; mean age 10 years; range 4 to 14 years) who were operated on after the first 24 hours for femoral neck fractures. According to the Delbet classification, two patients had type I, eleven patients had type II, and nine patients had type III fractures. Associated injuries were detected in seven patients. The mean duration from trauma to surgery was seven days (range 1 to 15 days). Internal fixation was performed following closed (n=20) or open (n=2) reduction. The results were assessed using the Ratliff criteria at the end of a mean follow-up of 73 months (range 18 to 184 months). The patients were evaluated with respect to age, type of fracture, displacement, complications, and avascular necrosis. RESULTS: The results were good in 12 (54.6%), fair in eight (36.4%), and poor in two patients (9.1%). Complications developed in 17 patients (77.3%), 12 of whom had more than one. The most frequent complication was premature physeal closure (n=14; 63.6%) followed by avascular necrosis (n=12; 54.6%). No significant differences were found (i) with regard to age and the type of fracture between patients with and without avascular necrosis, and (ii) with regard to avascular necrosis between patients who were treated within the first and second week of trauma (p>0.05). CONCLUSION: The results of surgery performed after the first 24 hours are mainly influenced by the occurrence of avascular necrosis and, secondarily, by the type of fracture.

When should the external approach be resorted to in the arthroscopic treatment of perimeniscal cyst?

INTRODUCTION: Meniscal cysts very often cause meniscal tears and especially when it is peripheral, some of the healthy parts of meniscus might be needlessly sacrificed. In particular conditions, extraarticular approaches might save some menisci. In the present study, we evaluated the conditions which required using the extraarticular approach in addition to the arthroscopic procedure, to maximally preserve the meniscus. METHODS: Eight patients with perimeniscal cysts were evaluated retrospectively. One cyst was localized within the medial meniscus and seven in the lateral meniscus. The mean age was 36.13 (range; 19-63) years, mean follow-up time, 27.3 (range; 12-47) months. Patients were evaluated by using a Visual Analogue Score (VAS) to measure pain relief and "Lysholm score" to measure functional improvement. In all patients except one, in which the cystic cavity was connected with the joint at the periphery of the meniscus, the cyst was drained from the intraarticular opening. When the cyst was too large (three cases) and in one case where a large amount of meniscus was preserved for reasons mentioned above, additional extraarticular drainage was carried out. RESULTS: The mean preoperative and postoperative VAS were 6 (range; 2-8) and 1.55 (range; 0-3) (p = 0.00058) and Lysholm scores were 64.75 (range; 48-86) and 93.11 (range; 80-100) (p = 0.0014), respectively. DISCUSSION: In cysts, which have very limited or no connection with the joint on the most peripheral region of the meniscus and/or are larger than the meniscus height, extraarticular drainage of the cyst might produce unnecessary meniscal loss and function. In the extraarticular drainage, scrapping the walls of the cyst, while inspecting with an arthroscope, reduces recurrence of the cyst.

[The effect of open wedge osteotomy on the posterior tibial slope]. / Açik kama osteotomisinin posterior tibial egim üzerine etkisi.

OBJECTIVES: Proximal tibial osteotomy improves the alignment and weight distribution of the lower extremity on the coronary plane. However, upper end osteotomy of the tibia may cause changes in the sagittal plane. In this study, we evaluated open wedge osteotomy operations with regard to its effect on the sagittal plane. METHODS: The study included 22 knees of 20 female patients (mean age 54.1 years; range 43 to 64 years) who underwent proximal tibial osteotomy for osteoarthritis. Open wedge osteotomy was performed in all the patients with the use of a Puddu plate. Pre- and postoperative posterior tibial slope angles were measured on lateral radiographs. The mean follow-up period was 12.8 months (range 4 to 33 months). RESULTS: Union of the osteotomy line was obtained in all the patients in a mean of 10.8 weeks (range 8 to 14 weeks). While the tibiofemoral range of motion did not change in 15 knees, it decreased by 5 to 10 degrees in seven knees postoperatively. Complaints of pain or limitation of the patellofemoral joint were observed in three patients. No correction loss or deep infection developed. The mean posterior tibial slope angle showed a significant increase by 3.5 degrees, from preoperative 7.2+/-4.1 degrees to postoperative 10.8+/-4.1 degrees (p<0.005). The more anteriorly the plate was placed in the osteotomy line, the higher increase in the posterior tibial slope angle was noted. CONCLUSION: These findings suggest that open wedge osteotomy results in a significant increase in the posterior tibial slope angle, which may be associated with the triangular shape of the upper end of the tibia, the design of the plate, and the site of plate application. The use of a plate with a decreasing height from posterior to anterior may decrease these changes in the posterior tibial slope angle.

[Diagnosis of septic arthritis and initial antibiotic treatment]. / Septik artritte tani ve baslangiç antibiyotik tedavisi.

OBJECTIVES: This study was designed to determine the similarities and differences in clinical, laboratory and radiographic presentation of septic arthritis in childhood and at adult ages, to find out its etiological profile, and to establish an antibiotic treatment protocol for the initial period and for patients in whom the causative agent could not be identified. METHODS: Thirty-four patients (age range 15 months to 85 years) who underwent surgery with a diagnosis of septic arthritis were retrospectively studied in two groups, namely, children-adolescents (age = or < 15 years ; 16 patients) and adults (age >15 years; 18 patients). Clinical and laboratory findings of septic arthritis were compared with operation findings. The etiological profile and sensitivity patterns were investigated. RESULTS: Unflatering features in both groups were clinical findings of decreased range of motion and tenderness, laboratory findings of elevated erythrocyte sedimentation rate and C-reactive protein, and domination of polymorphonuclear leukocytes in the joint fluid. Gram staining of the joint fluid was highly informative in terms of probable bacteria. During the first two years of life, the most common bacteria were H. influenzae and S. pneumoniae, and after two years, staphylococci and streptococci. Ciprofloxacin and sulbactam-ampicillin were found effective against most of the Gram-positive microorganisms isolated in both groups. CONCLUSION: The most useful test for septic arthritis is arthrosynthesis and macroscopic and microscopic analyses of the material. Gram staining is of great help in the planning of initial antibiotic treatment. For patients older than two years of age, treatment with sulbactam-ampicillin is effective against staphylococci and streptococci, and amikacin against Gram-negative bacteria. Detection of Gram-negative bacteria in patients younger than two years should bring H. influenzae in mind, for which ampicillin must be the first choice.