Role of Critical Shoulder Angle in Degenerative Type Rotator Cuff Tears: A Turkish Cohort Study.

BACKGROUND This retrospective study investigated the association between the critical shoulder angle (CSA) and the development of full-thickness rotator cuff tears (FTRCTs) in the Turkish population. The CSA is an imaging parameter that quantifies the relationship between the inclination of the glenoid and the lateral extension of the acromion in the coronal plane. The CSA is an anatomical measurement, and higher CSA values have been associated with an increased incidence of FTRCTs. However, there is a lack of data on CSA regarding the Turkish population. MATERIAL AND METHODS In this study, CSA measurements were recorded in 2 groups: 50 patients with FTRCT who had arthroscopic repair (group 1) and 50 age- and sex-matched individuals with no FTRCT detected by magnetic resonance imaging (group 2). Sex, age, affected side, dominant side, and smoking status were recorded for each patient. The CSA measurements of the affected sides were performed on true anterior-posterior view radiographs. RESULTS The results showed a statistically significant difference between the mean CSA values of group 1 (37.48°) and group 2 (33.53°), P<0.001. CSA values of 36 and above had a sensitivity of 73.58%, specificity of 74.47%, positive predictive value of 75%, and negative predictive value of 74.47% for detecting FTRCT. CONCLUSIONS CSA measurement on radiographs is a useful diagnostic tool in the Turkish population, and an above-average CSA value is associated with a significantly increased incidence of degenerative-type FTRCT.

Level of osteotomy is relevant to obtain better union and clinical results in patients with severe hip dysplasia operated on with total hip arthroplasty and shortening osteotomy using a cementless, rectangular femoral component.

INTRODUCTION AND OBJECTIVE: Total hip arthroplasty with rectangular femoral component and transverse osteotomy for patients with Crowe type 3 or 4 dysplasia yields successful results with varying radiological findings. This study aims to investigate the surgery and patient related factors associated with successful clinical and radiological results. PATIENTS AND METHODS: Fifty hips of 41 patients were retrospectively examined. Length and percentage of the stem passing the osteotomy level and canal fill ratio were measured. Radiological findings such as radiolucent lines (RL) around the stem, hypertrophic callus or an identifiable osteotomy line on X-ray images were assessed. All clinical and radiological results were analyzed for any significant association. RESULTS: Mean stem length and percentage passing the osteotomy level were 6.4 cm (± 0.7) and 51% (± 6). Presence of an identifiable osteotomy line was positively associated with the increasing length of the stem passing the osteotomy level and with a lower HHS (p < 0.05). RL around the stem were associated with a lesser reduction in VAS score (p < 0.05). CONCLUSION: Rectangular femoral stem conveniently accommodate the proximal femur in severely dysplastic hips. An upper limit for the femoral stem exists to obtain better bony union and higher HHS. RL around the stem are clinically relevant and is associated with a worse VAS score at the latest follow-up.

The role of serum D-dimer in the diagnosis of periprosthetic joint infection and timing of reimplantation.

D-dimer is a fibrin degradation product formed by the destruction of the cross-linked fibrin clot by activation of the coagulation system. Many studies have shown that systemic and local infections cause fibrinolytic activities. The purpose of this study was to determine the role of serum D-dimer in the diagnosis of periprosthetic joint infection (PJI) and the timing of reimplantation. The patients who underwent primary and revision knee or hip arthroplasty between July 2018 and May 2019 were prospectively evaluated. All surgeries were performed by the same surgeon. 60 of 71 patients who met our criteria were included in the study, comprising of 27 primary arthroplasties (PA), 21 two-stage septic revision (SR) and 12 aseptic revision (AR). We analyzed D-dimer, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels. The values of the septic group were evaluated as two groups; Group 1 (before the first stage) and Group 2 (before the second stage) to investigate the role of D-dimer in determining the timing of reimplantation. D-dimer level was significantly higher in the SR group compared to PA and AR groups (p<0.001 and p=0.045). CRP and ESR levels were significantly higher in the SR group compared to PA and AR groups. There was no statistically significant difference between preoperative D-dimer levels of Group 1 and Group 2 (p=0.2). Serum D-dimer level can be used as an easy and inexpensive test to support the diagnosis of PJI. But the D-dimer level is not useful to determine the timing of reimplantation.

Clinical and Radiological Results of Crowe Type 3 or 4 Dysplasia Patients Operated on With Total Hip Arthroplasty Using a Cementless Rectangular Femoral Component Without Fixating or Grafting the Transverse Osteotomy Site.

BACKGROUND: Total hip arthroplasty (THA) involving shortening osteotomy for patients with Crowe type 3 or 4 dysplasia is a challenging surgical procedure. This study aims to demonstrate that rectangular femoral component use in anatomical reconstructions with THA and transverse shortening osteotomy yields successful results without the use of bone graft or any fixation material at the osteotomy site. METHODS: Fifty hips from 41 patients were identified retrospectively as per study objectives. All patients were evaluated using the Harris Hip Score and Visual Analog Scale for pain. Complications were reported. Radiological evaluation criteria were then evaluated, including leg length discrepancy, degree of trochanter caudalization and stem subsidence, radiolucent and radiodense lines for both components and bone atrophy or hypertrophy around the stem according to Gruen zones, and the canal fill ratio of the stem. RESULTS: Postoperative Harris Hip Score was excellent for 68% of patients. No patient had poor results. Complication rate was 32%. One patient had nonunion (2%). The mean postoperative leg length discrepancy was 0.8(±0.6) cm. No patient had a subsidence of more than 5 mm. Radiolucent and radiodense lines were present in up to 34% of patients, and bone atrophy was present in the proximal femur in up to 96% of patients. No patient had osteolysis or loosening in neither component. CONCLUSION: Successful clinical and radiological results can be obtained from Crowe type 3 and 4 dysplastic hips operated on with THA using a rectangular femoral component and transverse shortening osteotomy technique. The use of graft or any fixation material at the osteotomy site is not mandatory.

Comparison of functional metacarpal splint and ulnar gutter splint in the treatment of fifth metacarpal neck fractures: a prospective comparative study.

BACKGROUND: Fifth metacarpal fractures are the most common fractures of the hand. These fractures are generally treated with conservative methods. The aim of this study was to compare the radiological and clinical outcomes of two conservative treatment methods, functional metacarpal splint(FMS) and ulnar gutter splint(UGS), for the treatment of fifth metacarpal neck fractures. METHODS: A prospective comparative study was designed to assess the conservative treatment of isolated and closed stable fractures of the fifth metacarpal neck. In total, 58 patients were included in the study and were treated with FMS or UGS after fracture reduction in a consecutive order. Angulation, shortening and functional outcome (QuickDASH scores and grip strengths) were evaluated at the 2nd and 6th months. RESULTS: Forty patients returned for follow-up. Twenty-two patients were treated with FMS, and 18 patients were treated with UGS. The average age was 28 years (SD ± 12, range;18-43) in the FMS group and 30 years (SD ± 14, range;18-58) in the UGS group. After reduction, significant correction was achieved in both groups, but the average angulation was lower in the FMS group(16 ± 7) compared with the UGS group (21 ± 8)(p = 0.043). However, this better initial reduction in FMS group(16 ± 7) could not be maintained in the 1st month follow-up (21 ± 5) (p = 0.009). In the FMS group, the improvement in QuickDASH scores between the 2nd and 6th month follow-up was significant (p = 0.003) but not in the UGS group(p = 0.075). When the expected grip strengths were calculated, the FMS group reached the expected strength values at the 2nd month follow-up, whereas the UGS group still exhibited significantly lower grip strength at the 2nd month follow-up(p = 0.008). However, at the end of the 6th month follow-up, both groups exhibited similar reduction, QuickDASH and grip strength values. CONCLUSIONS: In stable 5th metacarpal neck fractures, FMS is adequate to prevent loss of reduction and yields faster improvement in clinical scores with earlier gain of normal grip strength compared with UGS. However, in the long term, both FMS and UGS methods yield similar radiological and clinical outcomes. Patient comfort and compliance may be better with FMS due to less joint restriction, and these findings should be considered when deciding the treatment method. TRIAL REGISTRATION: ISRCTN79534571 The date of registration: 01/04/2019 Type of study/level of evidence: Therapeutic, II.

Bilateral High Hip Center Provides Gait Parameters Similar to Anatomical Reconstruction: A Gait Analysis Study in Hip Replacement Patients With Bilateral Developmental Dysplasia.

BACKGROUND: Total hip arthroplasty in severe dysplasia is challenging due to diminished periacetabular bone stock and the highly placed femoral head. Although anatomical reconstruction of the hip, with required interventions such as subtrochanteric osteotomy and graft usage, is the main aim of the procedure, good long-term clinical outcomes of the high hip center technique have also been reported. Information regarding the effect of hip center placement on gait characteristics is limited; therefore, the aim of this study is to analyze the differences in gait parameters between the high hip center technique and anatomical reconstruction of the hip. METHODS: Twenty patients (40 hips) with bilateral Crowe type III-IV developmental dysplasia of the hip who underwent bilateral total hip arthroplasty and completed at least 2 years of follow-up were included. Group 1 comprised 10 patients (20 hips) who underwent anatomical hip center reconstruction, while group 2 comprised 10 patients (20 hips) who underwent high hip center reconstruction. The gait characteristics of patients were examined through markers placed in certain anatomical regions, the cameras placed around, and the force plates embedded in the walking platform. RESULTS: There was no significant difference in the gait characteristics according to the location of the hip rotation center. The mean temporospatial, kinematic, and kinetic values were similar between the groups. The most prominent difference was in the peak dynamic hip extension, which was lower in group 2 (-9.71° ± 7.46°) compared to group 1 (-6.80° ± 11.44°), although it was not statistically significant (P = .09). CONCLUSION: The bilateral high hip center technique can provide similar gait characteristics as anatomical reconstruction and may be preferred in particularly difficult cases based on the surgeon's decision.

[Management of refractory ventricular tachycardia using stereotactic body radiotherapy]. / Prise en charge des tachycardies ventriculaires réfractaires par radiothérapie stéréotaxique.

Stereotactic body radiotherapy (SBRT) is routinely used in oncology to treat non-invasively solid tumors with high precision and efficacy. Recently, this technology has been evaluated in the treatment of ventricular tachycardia (VT). This article presents the basic underlying principles, proofs of concept and main results of clinical studies that used SBRT for the treatment of VT.

La radiothérapie stéréotaxique (SBRT) est une technologie couramment utilisée en oncologie pour traiter de façon non invasive les tumeurs solides avec précision et efficacité. Récemment, cette technologie a été évaluée dans le traitement des tachycardies ventriculaires (TV). Cet article présente les principes de base sous-jacents, le concept ainsi que les résultats des premières études cliniques ayant traité avec succès des patients souffrant de TV avec la SBRT.

Locoregional Control and Toxicity in Head and Neck Carcinoma Patients following Helical Tomotherapy-Delivered Intensity-Modulated Radiation Therapy Compared with 3D-CRT Data.

OBJECTIVES: To assess the feasibility and efficacy of intensity-modulated radiation implemented with helical tomotherapy image-guided with daily megavoltage computed tomography for head and neck cancer. METHODS: Between May 2010 and May 2013, 72 patients were treated with curative intent. The median age was 64 years, with 57% undergoing definitive and 43% postoperative radiotherapy. Primary tumour sites were oral cavity (21%), oropharynx (26%), hypopharynx (20%), larynx (22%), and others (11%). Staging included 4% stage I, 15% II, 26% III, 48% IVa, and 7% IVb. Radiotherapy was combined with chemotherapy in 64%. Primary endpoint was locoregional control, and secondary endpoints survival and toxicity. RESULTS: Median follow-up was 20 months, with 11 locoregional recurrences. Three-year disease-free survival was 58% and overall survival 57%. In the multivariate analysis, age under 64 years, no extracapsular extension, postoperative radiotherapy, induction chemotherapy, and non-oral cavity tumour were significant favourable prognostic factors for disease-free-survival. The overall incidence of acute grade ≥3 toxicities were mucositis 32%, pain 11%, xerostomia 7%, dysphagia 53%, radiodermatitis 44%, and osteonecrosis 1%. Late grade ≥3 toxicities were fibrosis 6%, dysphagia 21%, fistula 1%, and skin necrosis 1%. CONCLUSIONS: Intensity-modulated radiation with helical tomotherapy achieved respectable locoregional control and overall survival, with acceptable toxicity, in head and neck cancer patients.

Adult prostatic sarcoma: A contemporary multicenter Rare Cancer Network study.

INTRODUCTION: Adult prostatic sarcoma (PS) is a rare disease. While surgery is considered the standard approach, the role of other therapies is not completely established. We report results of the largest multicentric contemporary cohort of PS patients. MATERIALS AND METHODS: This study included 61 adult PS patients treated in 16 American and European Institutions. Median age was 64.4 years (range: 22-87). Curative surgery was delivered in 48 patients (prostatectomy = 26, cystoprostatectomy = 22), usually with lymphadenectomy (n = 40). Curative radiotherapy (RT) was delivered in 32 patients, as radical (n = 5), neoadjuvant (n = 10), or postoperative treatment (n = 17). Eighteen patients received chemotherapy. None of the patients received hormonal therapy. RESULTS: Median follow-up was 72 months (95%CI: 55-not reached). Five-year local control (LC), overall survival (OS), cancer-specific survival, disease-free survival, and metastases-free rates were 47%, 53%, 56%, 35%, and 35%, respectively. Notably, curative RT (neoadjuvant, adjuvant, or definitive) was associated with improved 5-year LC (55% vs. 31%, P = 0.02) and OS (59% vs. 46%, P = 0.1). Surgically treated patients presenting with a cT3-4 tumor (n = 31), who received RT (n = 24), had a significantly improved 5-year LC (68% vs, 33%, P = 0.004) and OS (65% vs. 21%, P < 0.001) rates compared to patients not receiving RT. cT4 patients demonstrated a significantly lower 5-year OS (43% vs. 61%, P = 0.006) and LC (29% vs. 69%, P < 0.001) rates. Histologic subtype was not associated with LC and OS, but patients with prostatic stromal sarcoma, rhabdomyosarcoma, or sarcomatoid carcinoma had worse 5-year LC compared to other types (47% vs. 55%) and OS (49% vs. 58%). CONCLUSION: Adult PS has a poor prognosis. Locally advanced tumors have poor LC and OS rates. Curative RT should be considered part of the multidisciplinary approach to PS.

Outcome and prognostic factors in 110 consecutive patients with primary uterine leiomyosarcoma: A Rare Cancer Network study.

OBJECTIVE: Primary uterine leiomyosarcomas (ULMS) are rare, and the optimal treatment is controversial. We aimed to assess the outcome and prognostic factors in a multicenter population of women treated for primary ULMS. METHODS: We retrospectively collected data of 110 women treated in 19 institutions of the Rare Cancer Network (RCN). Inclusion criteria consisted of a pathology report confirming the diagnosis of ULMS, aged 18-80 years, complete International Federation of Gynecology and Obstetrics (FIGO) stage information, complete information on treatment, and a minimum follow-up of 6 months. Local control (LC) and locoregional control (LRC), overall survival (OS) and disease-free survival (DFS) rates were computed using the Kaplan-Meier method. Univariate analysis was implemented using the log rank test, and multivariate analysis using the Cox model. RESULTS: All patients underwent surgery. Seventy-five patients (68%) received adjuvant radiotherapy (RT), including brachytherapy in 18 (16%). Seventeen patients (15%) received adjuvant chemotherapy. Median follow-up was 58 (range, 6-240) months. Five-year OS and DFS rates were 50% and 34%, and LC and LRC rates were 88% and 72%, respectively. On multivariate analysis, independent favorable prognostic factors were younger age, FIGO stage I, small tumor size, previous uterine disease, and no vascular invasion for OS and DFS. FIGO stage was the only favorable factor influencing LRC. Adjuvant local or systemic treatments did not improve the outcomes. Eight patients treated with RT presented a grade 3 acute toxicity, and only one patient with grade 3 late toxicity. CONCLUSIONS: In this large population of primary ULMS patients, we found good results in terms of LC and LRC. Nevertheless, OS remains poor, mainly due to the occurrence of distant metastases. An early diagnosis seemed to improve the prognosis of the patients. Adjuvant local or systemic treatments, or more aggressive surgical procedures such as the Wertheim procedure, did not seem to impact the outcome.

Panitumumab plus radiotherapy versus chemoradiotherapy in patients with unresected, locally advanced squamous-cell carcinoma of the head and neck (CONCERT-2): a randomised, controlled, open-label phase 2 trial.

BACKGROUND: We aimed to compare panitumumab, a fully human monoclonal antibody against EGFR, plus radiotherapy with chemoradiotherapy in patients with unresected, locally advanced squamous-cell carcinoma of the head and neck. METHODS: In this international, open-label, randomised, controlled, phase 2 trial, we recruited patients with locally advanced squamous-cell carcinoma of the head and neck from 22 sites in eight countries worldwide. Patients aged 18 years and older with stage III, IVa, or IVb, previously untreated, measurable (≥ 10 mm for at least one dimension), locally advanced squamous-cell carcinoma of the head and neck (non-nasopharygeal) and an Eastern Cooperative Oncology Group performance status of 0-1 were randomly assigned (2:3) by an independent vendor to open-label chemoradiotherapy (two cycles of cisplatin 100 mg/m(2) during radiotherapy) or to radiotherapy plus panitumumab (three cycles of panitumumab 9 mg/kg every 3 weeks administered with radiotherapy) using a stratified randomisation with a block size of five. All patients received 70-72 Gy to gross tumour and 54 Gy to areas of subclinical disease with accelerated fractionation radiotherapy. The primary endpoint was local-regional control at 2 years, analysed in all randomly assigned patients who received at least one dose of their assigned protocol-specific treatment (chemotherapy, radiation, or panitumumab). The trial is closed and this is the final analysis. This study is registered with ClinicalTrials.gov, number NCT00547157. FINDINGS: Between Nov 30, 2007, and Nov 16, 2009, 152 patients were enrolled, and 151 received treatment (61 in the chemoradiotherapy group and 90 in the radiotherapy plus panitumumab group). Local-regional control at 2 years was 61% (95% CI 47-72) in the chemoradiotherapy group and 51% (40-62) in the radiotherapy plus panitumumab group. The most frequent grade 3-4 adverse events were mucosal inflammation (25 [40%] of 62 patients in the chemoradiotherapy group vs 37 [42%] of 89 patients in the radiotherapy plus panitumumab group), dysphagia (20 [32%] vs 36 [40%]), and radiation skin injury (seven [11%] vs 21 [24%]). Serious adverse events were reported in 25 (40%) of 62 patients in the chemoradiotherapy group and in 30 (34%) of 89 patients in the radiotherapy plus panitumumab group. INTERPRETATION: Panitumumab cannot replace cisplatin in the combined treatment with radiotherapy for unresected stage III-IVb squamous-cell carcinoma of the head and neck, and the role of EGFR inhibition in locally advanced squamous-cell carcinoma of the head and neck needs to be reassessed. FUNDING: Amgen.

Long-term outcome and late side effects in endometrial cancer patients treated with surgery and postoperative radiation therapy.

BACKGROUND: We retrospectively reviewed the long-term outcome and late side effects of endometrial cancer (EC) patients treated with different techniques of postoperative radiotherapy (PORT). METHODS: Between 1999 and 2012, 237 patients with EC were treated with PORT. Two-dimensional external beam radiotherapy (2D-EBRT) was used in 69 patients (30 %), three-dimensional EBRT (3D-EBRT) in 51 (21 %), and intensity-modulated RT (IMRT) with helical Tomotherapy in 47 (20 %). All patients received a vaginal brachytherapy (VB) boost. Seventy patients (29 %) received VB alone. RESULTS: After a median of 68 months (range, 6-154) of follow-up, overall survival was 75 % [95 % confidence interval (CI), 69-81], disease-free survival was 72 % (95% CI, 66-78), cancer-specific survival was 85 % (95 % CI, 80-89), and locoregional control was 86 % (95 % CI, 81-91). The 5-year estimates of grade 3 or more toxicity and second cancer rates were 0 and 7 % (95 % CI, 1-13) for VB alone, 6 % (95 % CI, 1-11) and 0 % for IMRT + VB, 9 % (95 % CI, 1-17) and 5 % (95 % CI, 1-9) for 3D-EBRT + VB, and 22 % (95 % CI, 12-32) and 12 % (95 % CI, 4-20) for 2D-EBRT + VB (P = 0.002 and P = 0.01), respectively. CONCLUSIONS: Pelvic EBRT should be tailored to patients with high-risk EC because the severe late toxicity observed might outweigh the benefits. When EBRT is prescribed for EC, IMRT should be considered, because it was associated with a significant reduction of severe late side effects.

Long-Term Results of Stereotactic Radiotherapy in Patients with at Least 10 Brain Metastases at Diagnosis.

PURPOSE: to evaluate an SRT approach in patients with at least 10 lesions at the time of BM initial diagnosis. METHODS: This is a monocentric prospective cohort of patients treated by SRT, followed by a brain MRI every two months. Subsequent SRT could be delivered in cases of new BMs during follow-up. The main endpoints were local control rate (LCR), overall survival (OS), and strategy success rate (SSR). Acute and late toxicity were evaluated. RESULTS: Seventy patients were included from October 2014 to January 2019, and the most frequent primary diagnosis was non-small-cell lung cancer (N = 36, 51.4%). A total of 1174 BMs were treated at first treatment, corresponding to a median number of 14 BMs per patient. Most of the patients (N = 51, 72.6%) received a single fraction of 20-24 Gy. At 1 year, OS was 62.3%, with a median OS of 19.2 months, and SSR was 77.8%. A cumulative number of 1537 BM were treated over time, corresponding to a median cumulative number of 16 BM per patient. At 1-year, the LCR was 97.3%, with a cumulative incidence of radio-necrosis of 2.1% per lesion. Three patients (4.3%) presented Grade 2 toxicity, and there was no Grade ≥ 3 toxicity. The number of treated BMs and the treatment volume did not influence OS or SSR (p > 0.05). CONCLUSIONS: SRT was highly efficient in controlling the BM, with minimal side effects. In this setting, an SRT treatment should be proposed even in patients with ≥10 BMs at diagnosis.

Double Dislocation of the Interphalangeal Joints of the Little Finger.

High-energy traumas may lead to the dislocation of joints with or without fractures. However, simultaneous double dislocation of the proximal and distal interphalangeal joints (PIP and DIP) in fingers shows up rarely. Although it can be inferred as simultaneous dislocation occurring during the same trauma, consecutive events should be taken into consideration. A 29-year-old, right-hand dominant male patient presented to the emergency room with a left little finger deformity after being hit by a ball while playing football. Despite the inability to move the little afteruent to this hyperextension injury, there was mild swelling, ecchymosis, and pain with no trace of laceration or neurovascular injury. PIP and DIP joint dislocations of the left-hand little finger with distal phalanx proximal fracture were detected on the radiograph indicating a stepladder deformity. Closed reduction was achieved by longitudinal traction and applying pressure over the base of the dislocated digit. Afterward, an aluminum finger splint was applied to the little finger in the functional position to prevent further damage. Re-evaluation radiographs revealed a successful reduction of both joints. Immobilization via an aluminum finger splint was recommended for three weeks. Subsequently, range of motion exercises and rehabilitation were started. Three-month follow-up revealed an almost full range of motion in both PIP and DIP joints without stiffness and pain. Although double dislocation seems to present with more painful and swollen fingers than single dislocations, it can also present with mild pain and swelling, as in this case. The little finger is easily exposed to traumas due to the lack of surrounding tissue. Therefore, double dislocation is mostly seen in the little finger. This case report briefly illustrates a rare incidence of double dislocation involving both the PIP and DIP joints of the little finger. Normal range of motion of both joints was reached by early reduction followed by timely rehabilitation.

Match the Metatarsal Heads: A Case of All-Metatarsal Fractures After a Motorcycle Accident.

Metatarsal bone fractures are one of the most frequent foot injuries, especially after motor vehicle accidents in children. This case report briefly demonstrated a rare instance of pediatric all-metatarsal fractures of the left foot in an adolescent patient with polytrauma after a motorcycle accident. This case report illustrated the surgical procedure's potential for healing pediatric foot fractures in teenage patients after polytrauma. In the examination of a 16-year-old male patient brought to the emergency department after a motorcycle accident, we detected a right foot third finger proximal phalanx open fracture, right foot fourth finger proximal phalanx fracture, left foot first metatarsal proximal fracture, left foot second, third, fourth, and fifth metatarsal distal fractures, left foot cuboid, and navicular bone fractures. The patient's left foot's metatarsals were all fractured. The posterolateral wall fracture of the patient's right maxilla was also detected. All metatarsals were displaced, the second metatarsal paired with the third, etc., and because of this displacement, the closed reduction was impossible, and even the open reduction was challenging to reach the correct pairs. We performed closed reduction and fixation with Kirschner wire for the left foot's first metatarsal fracture and open reduction and fixation with Kirschner wire for the left foot's second, third, and fourth metatarsal distal fractures. We also performed closed reduction and fixation with Kirschner wire for the right foot third and fourth proximal phalanx fractures. We observed callus formation in the sixth week and removed the patient's K-wires. At eight weeks, the X-ray demonstrated the correct alignment of all metatarsals. The proper alignment of all metatarsals and the full range of motion of all foot and ankle joints were achieved with early surgical intervention, open reduction, and timely rehabilitation. This case also emphasizes the importance of open reduction in such irreducible and heavily displaced cases of multiple fractures as all-metatarsal fractures and contributes to the literature with a specific treatment modality in the case of all-metatarsal fractures lacking in the literature.

A Case of Malignant Myxofibrosarcoma With Hypoglycemia Attacks.

Myxofibrosarcoma is a malignant mesenchymal tumor and a fibroblastic sarcoma of the elderly. Myxofibrosarcoma can be low-grade or high-grade depending on the cell characteristics. Wide surgical resection with or without radiotherapy and chemotherapy is the basis of its treatment. Sometimes, tumor cells secrete insulin or insulin-like substances and cause hypoglycemia attacks. Here, we intend to demonstrate the role of early surgery to end hypoglycemia attacks and prevent recurrence and metastases. We also intend to show the insufficiency of tru-cut biopsy to distinguish between low- and high-grade myxofibrosarcoma. An 82-year-old male patient visited our clinic with a rapidly growing giant mass in the left retroscapular area and suffered from hypoglycemic attacks several times a day. After imaging and initial biopsy, the tumor grade was indeterminate on histopathological examination; hence, the mass was removed surgically. The pathological examination resulted in high-grade myxofibrosarcoma whereas the initial biopsy could not elaborate on the grade. The hypoglycemia attacks ceased after the surgery. Adjuvant local radiotherapy at a total dose of 60 Gy was administered in 30 fractions to the surgery area with no complications after the surgery. No new mass, recurrence, or hypoglycemia attack was detected in the three-year follow-up. In conclusion, hypoglycemia attacks may be a marker of malignant tumor presence and may be a clue at the beginning and in the follow-up period both for recurrence and the aggressiveness of the tumoral mass. Because a biopsy may show the diagnosis but not the grade of the tumor, early surgical intervention is needed.

Case Report of a Patient With Malignant Peripheral Nerve Sheath Tumor Treated With Wide Resection.

Malignant peripheral nerve sheath tumors are soft tissue sarcomas originating from peripheral nerves. They are more frequently diagnosed in individuals with neurofibromatosis and tend to affect young men more often than women. The most common sites for these tumors within the peripheral nerve sheath are in the pelvis and the distal femur. Although chemotherapy and radiotherapy are not frequently used, it should be noted that in some cases, postoperative radiotherapy and chemotherapy may be beneficial. The primary treatment approach typically involves the complete surgical removal of the tumor. Here, we discuss the case of our patient whom we successfully treated with extensive resection and followed up with postoperative radiotherapy at our clinic.

Diagnosis and Treatment Planning of Developmental Hip Dysplasia: Evaluation of Care Practices of the Members of the Turkish Pediatric Orthopedics Association.

OBJECTIVE: Developmental dysplasia of the hip is one of the most important causes of childhood disabilities. Although there are accepted treatment algorithms for developmental dysplasia of the hip, diagnosis and treatment approaches can show variations in the management among physicians. This study aimed to develop a diagnosis and treatment algorithm for developmental dysplasia of the hip according to the preferences of members of the Turkish Pediatric Orthopedics Association. MATERIALS AND METHODS: An interview by telephone call was made with 76 orthopedists (group 1: more experienced 39 physicians, group 2: less experienced 37 physicians) who are members of the Turkish Pediatric Orthopedics Association. Participants were q uesti onnai red ab out their demographic information, experiences, diagnostic criteria that they use for developmental dysplasia of the hip, and treatment approaches to patient scenarios of different ages. RESULTS: Most of the participants recommended universal screening at the age of 4 weeks. It was observed that the most significant physical examination finding was limited hip abduction, and the most frequently used radiographic evaluation on x-ray was acetabular index measurement. The most frequently used description for dysplasia was found as acetabular index >30°. CONCLUSIONS: Although there are some differences among orthopedists in the diagnosis, treatment, and follow-up approach of developmental dysplasia of the hip, there was no significant difference according to the experience-based grouping. The treatment algorithm, which was created with the most frequently given answers, was designed, which we think may be beneficial for pediatricians and orthopedists.

Evaluation of patients' post-operative results operated for hip fracture with computerized dynamic posturography: Proximal femoral nailing versus hip arthroplasty.

BACKGROUND: Proximal femoral nailing (PFN) and hip arthroplasty (HA) are the two most often utilized surgical procedures for treating hip fractures in older patients. The post-operative postural balance and functional outcomes of patients may be significantly influenced by the technical distinctions between PFN and HA. This will influence the surgeon's preferred course of therapy. To examine the functional outcomes of patients treated with PFN and HA following a hip fracture, this study used computerized dynamic posturography (CDP). The aim of that study was to evaluate how the two treatment modalities affected patients' post-operative balance, postural stability, and functional rehabilitation. METHODS: A total of 26 patients who underwent proximal femoral surgery (15 patients PFN [58%] and 11 patients HA [42%]) due to hip fractures were evaluated at least 12 months postoperatively. They were tested by direct radiographs, hip joint examinations, Harris hip score (HHS), and CDP. RESULTS: Twelve (46%) of 26 patients were male and 14 (54%) were female. The mean age of the participants in the study was 67.9±14.2 years. The mean follow-up period was 24 (12-44) months. The average Harris score of PFN group was 79.3 (46.8-100) points and HA group was 83.7 (61.9-99.9) points. There was no significant difference between the groups in terms of Harris Score (P=0.54). The average of the mixed value of the balance results obtained with CDP (the Composite score) for PFN group was 70.5 (56-79) points, and for HA group was 71.9 (56-83) points. There was no significant difference between the groups in terms of the Composite Score (P=0.47). Accordingly, 12 (80%) of the patients who underwent PFN had good results and 3 (20%) of them had bad results. Eight (72.7%) of those who underwent HA had good results and 3 (27.3%) had bad results. There was no statistically significant difference (P=0.66). CONCLUSION: Comparing the composite score for balance results and HHS results for rehabilitation with the data of the patients who underwent PFN and HA, there was no statistically significant difference between these two techniques in terms of postural stabil-ity and balance as a result of CDP examination.