Intraobserver and Interobserver Reliability of the Computed Tomography-Based Classifications Used in Posterior Malleolar Fractures: The Haraguchi and Bartonícek-Rammelt Classifications.

BACKGROUND: Three main computed tomography (CT)-based classification systems have been defined and used for posterior malleolar fractures. The intraobserver and interobserver reliability of two of these systems has never been investigated. The aim of this study was to investigate the intraobserver and interobserver reliability of the Haraguchi (HC) and Bartonícek-Rammelt (BRC) classifications. METHODS: Axial and sagittal CT sections and three-dimensional reconstruction images of 60 fractures were evaluated twice by six observers at a 6-week interval. Cohen κ values for intraobserver reliability and Fleiss κ values for interobserver reliability were calculated. RESULTS: The interobserver reliability of the HC was fair in both assessments (Fleiss κ: 0.263 and 0.249 for the first and second evaluations, respectively). The interobserver reliability of the BRC was moderate in both evaluations (Fleiss κ: 0.535 and 0.447, respectively). The intraobserver reliability values (Cohen κ) of the HC were determined to be between 0.532 and 0.927 for the six observers. These values indicated moderate agreement for one observer, substantial for four, and very good for one. Intraobserver reliability values for the BRC were determined to be between Cohen κ of 0.626 and 0.884. Based on these values, the BRC's intraobserver reliability indicated substantial agreement for two observers and very good for four observers. CONCLUSIONS: Intraobserver and interobserver reliability values of the BRC were higher than those of the HC.

How Reliable Are Digital Radiographs for Evaluating Intra-articular Displacement in Ankle Epiphyseal Fractures: Can Computed Tomography Be Eliminated?

BACKGROUND: The amount of intra-articular displacement of the fracture is the main issue when deciding the treatment method between conservative or surgical means in intra-articular fractures. In this study, we aimed to determine the intraobserver and interobserver reliability of measuring intra-articular displacement and to compare the digital radiographic and computed tomographic (CT) evaluations in distal tibia intra-articular epiphyseal fractures. METHODS: Thirty-seven patients with digital radiography and CT scans were included in the study. Four sets were prepared with these images. Two of four sets were prepared as ankle radiographs, and the other two sets were prepared with CT scan views. Five observers were asked to measure the intra-articular displacement of the fractures in millimeters and also to make a decision between displacement amounts over or under 2 mm. Intraclass correlation coefficient scores were calculated for evaluation of intraobserver reliability, and Fleiss kappa values were calculated for interobserver reliability evaluations. A value greater than 0.75 was accepted as excellent agreement; 0.75 to 0.40 as intermediate to good agreement; and below 0.40 as poor agreement. RESULTS: There were 15 Salter-Harris type 3, 13 Salter-Harris type 4, seven triplanar, and two Tillaux-Chaput fractures. Both intraobserver and interobserver reliabilities were slightly higher for CT scan evaluations. Amounts of displacement were found to be measured higher after CT scan evaluations other than radiographs. After the measurement of joint displacements on CT scans, it was observed that the measurements found below 2 mm on the digital radiograph measurement changed to greater than or equal to 2 mm in 16.4% of the patients. CONCLUSIONS: This study confirmed that digital radiographs cannot replace CT scans for the measurement of intra-articular displacement in ankle epiphyseal fractures.

Comparison of the Reliability of Three Scoring Systems Used to Decide Whether to Apply Cement in Hip Arthroplasty Among Fracture Patients and the Effect of Surgical Experience: The Spotorno, Dorr, and Canal Flare Indices.

BACKGROUND: No consensus has been reached regarding the best index to decide whether to use cement during hip replacement surgery. Therefore, this study compared the reliability of three frequently used scoring systems. The secondary purpose was to evaluate the effect of surgical experience on the decision to use cement. METHODS: Anteroposterior radiographs of 60 hips were assessed by four orthopedic surgeons and four orthopedic residents. The observers were asked to make measurements using the Spotorno criteria, the Dorr index, and the canal flare index, and to decide whether to use a cemented or cementless femoral stem. The same X-rays were sent to all participants, in a different order, 4 weeks later, for a second evaluation. The SPSS software (version 24.0) was used for the statistical analysis. Intraobserver agreement was determined for all observers via the intraclass correlation coefficient (ICC), and interobserver reliability was calculated using the weighted kappa (κ) statistic. RESULTS: The average age of the patients were 73.1 ± 12.1 years. Thirty-three (55%) patients were female and thirty-two (53.3%) had fractures on the right side. Intraobserver agreement was "excellent" for all participants according to the Spotorno criteria. The canal flare index had the lowest intra-observer agreement. The highest interobserver agreement was found using the Spotorno criteria. CONCLUSION: The intra- and interobserver reliabilities of the Spotorno criteria were higher than those of the Dorr index and the canal flare index. The Spotorno criteria was more useful for deciding between cemented and un-cemented hip arthroplasty.

Alterations in serum IL-6 levels in traumatized pediatric patients: A preliminary study for second hit concept.

BACKGROUND: The inflammatory response of pediatric patients to multiple injuries can be monitored by serum interleukin-6 levels. The aim of this study was to investigate the severity of the inflammatory response accordingly interleukin-6 (IL-6) which have not been evaluated before. METHODS: There were 30 patients with an isolated long-bone fracture in group 1 and 49 patients with multi-system injury with at least a fracture in group-2. In group-2 were divided into two subgroups according to MISS (cut-off value = 17). Group-3 was composed of 100 healthy children as the control group to determine the normal range of serum IL-6 levels. In group-2, blood samples were taken on the 3rd, 5th, and 10th days, and if the patient was operated, additional samples were taken before the surgery and on the postoperative 1st, 5th, and 10th days. The relationship between trauma severity and serum IL-6 levels was analyzed statistically. RESULTS: Mean serum IL-6 levels were 16.1, 46.4, 74.2 and 8.6 pg/mL respectively (group-1, -2A, -2B, and -3). There was a moderate correlation between MISS and IL-6 (p < 0.001). In group-2A, mean serum IL-6 levels were 13.9 pg/mL on the 3rd day and 9.1 on the 10th day. In group-2B they were 15.4 and 4.7 pg/mL, respectively. Also, for the patients undergoing surgically in group-2A, they were 36.0 pg/mL before the surgery, 33.2 on the 1st day, and 6.0 on the 10th day. For group-2B, they were 39.3, 37.4, and 7.9 pg/mL, respectively. CONCLUSION: It was determined that serum IL-6 levels were significantly increased with increasing trauma severity. Systemic inflammation specified by IL-6 could decrease to almost normal on the 3rd day, and regress to normal on the following days. The concept of "second hit impact following surgical procedure" may also be kept in mind in children as in adults considering these alterations.

Does the size of Thurston-Holland fragment have an effect on premature physeal closure occurrence in type 2 distal tibia epiphyseal fractures?

The purpose of this study was to investigate the possible effect of Thurston-Holland fragment (THF) size on the development of premature physeal closure (PPC) in distal tibia type 2 epiphyseal injuries. Fifty-eight fractures in 57 patients with a minimum follow-up period of 12 months were included. For statistical analysis, sex and age of the patient, number of reduction attempts, percentage of THF base relative to physis length on anteroposterior or lateral radiograph, maximal initial and postreduction displacement amount, presence of accompanying fibula fracture and trauma mechanism were evaluated. PPC was observed in 12 fractures (20.7%). An increased amount of initial displacement, increased number of reduction attempts and passing the physis with three Kirschner wires were determined as statistically significant factors for PPC occurrence (P = 0.011, 0.011 and 0.005, respectively). The THF percentage was not found to be an important factor for the occurrence of PPC. In males, THF size was less than 50% more frequently than that in females (P = 0.013). THF size had no significant effect on PPC occurrence after distal tibial epiphyseal fractures.

Analysis of the factors that are important in re-displacement in pediatric diaphyseal femur fractures treated with a spica cast.

BACKGROUND: There is no detailed data on the factors affecting the re-displacement in pediatric femoral fractures treated with closed reduction and early spica casting. This study aimed to investigate the factors effective in re-displacement in pediatric diaphyseal femur fractures (PDFF) treated with spica casting. METHODS: In all, 151 displaced PDFF were evaluated retrospectively. Demographic data of the patients were evaluated. Type of fractures, anteroposterior and lateral angulations, amount of shortening, translation ratio, cast index (CI), gap index (GI), and three-point index (TPI) measurements were evaluated radiologically. Thigh flexion angle (TFA) and knee flexion angle (KFA) were measured. After casting, angulation of more than 10° in any plane and a shortening of more than 10 mm was accepted as re-displacement. Binary logistic regression analysis was used to evaluate the risk factors of re-displacement. Receiver operating characteristic analysis was performed for TFA and KFA. RESULTS: Re-displacement was detected in 40 patients (26.5%). Transverse type fracture (p = 0.001), TFA ˂71.4° (p <0.001), and KFA ˂52.6° (p = 0.002) were found to be statistically significant factors on re-displacement. It was determined that the combination of transverse femoral fracture and TFA ˂71.4° increased the probability of re-displacement by approximately 14 times. It has been observed that indices such as CI, GI, and TPI were not effective in predicting the risk of re-displacement. CONCLUSION: When treating a PDFF with spica casting, one should be aware of re-displacement if the fracture type is transverse, TFA is ˂71.4°, and KFA is ˂52.6°. LEVEL OF EVIDENCE: Level III, prognostic.

Jaffe Lichtenstein Type of Polyostotic Skeletal Fibrous Dysplasia With the Involvement of Cranial Bones.

ABSTRACT: Fibrous dysplasia (FD), a benign fibro-osseous bone tumor commonly involving the craniofacial region, presents a wide spectrum of radiographic patterns. When FD lesions are suspected, various imaging modalities and histopathologic analyses may be required to reach a firm diagnosis. Here, the authors report the case of a 10-year-old male patient presenting with polyostotic type of FD with follow-up data for the next 9 years. The patient showed involvement of cranial bones and bilateral femurs, with skin pigmentation and no endocrine disease, consistent with the diagnosis of Jaffe Lichtenstein disease. The craniofacial radiographic features obtained with computed tomography and cone-beam computerized tomography are documented in this article.

Instant messaging application usage for clinical consultation among orthopedic surgery residents in Turkey: A survey study.

OBJECTIVE: This study aimed to determine the characteristics of instant messaging application (IMA) usage for clinical consultation among orthopedic residents in Turkey and to explore their experiences and opinions concerning potential legal problems. METHODS: A questionnaire titled "Instant messaging for consultation among orthopedic surgeons" consisting of 21 questions was applied to orthopedic surgery residents, and the results were analyzed. The questions were designed to obtain information on 4 categories: 1) demographics and professional experience, 2) attitudes on the use of cellular phones, 3) IMA usage for clinical consultation purposes, and 4) problems and comments on smartphone application usage for clinical consultation purposes. The participants who had no experience with a smartphone or IMA usage were excluded at the final analysis. RESULTS: A total of 860 orthopedic residents (849 males [98.7%]; mean age=28.6 years; age range=22-44 years) participated in the survey (participation rate: 97.3%). The distribution of residency years was as follows: 1st year, 27%; 2nd year, 21.4%; 3rd year, 18.4%; 4th year, 17.4%; and 5th year, 49.9%. The most frequently used IMAs were WhatsApp (99.3%), Facebook Messenger (14.8%), Viber (8%), and Tango (1.3%). The rate of IMA usage for consultation was 95.3%. The most common reasons to prefer IMAs for consultation were being "fast" and "easy," but only 26.3% of the residents reported that they prefer the use of IMAs because they find them "reliable." Moreover, 41.7% of the respondents reported that they had an experience of misdiagnosis owing to the use of IMAs; 81.2% of the participants used the personal information of the patients during the consultation; 57.6% of the respondents considered that legal problems may arise because of the use of IMAs during the consultation; and 51.4% believed that an electronic platform, solely for consultation purposes, is required. CONCLUSION: This survey has shown that it is necessary to make some legal regulations regarding the use of IMAs for consultation purposes and to develop applications only for medical consultation purposes. Most of the trainees make decisions using IMAs without a proper examination, putting the patients at the risk of misdiagnosis. Moreover, the confidentiality of the patient's personal information appears to be in danger when IMAs are used. LEVEL OF EVIDENCE: Level IV, Diagnostic Study.

Evaluation of clinical findings and neurofibromatosis type 1 bright objects on brain magnetic resonance images of 60 Turkish patients with NF1 gene variants.

Neurofibromatosis type 1 (NF1) is caused by mutations in the NF1 gene. This retrospective study aims to evaluate the clinical manifestations and brain magnetic resonance images (MRI) analysis in 60 genetically confirmed NF1 patients. The results of next-generation sequencing (NGS), Sanger sequencing, and MLPA of NF1 gene were evaluated. A total of 54 different variants were identified. Fourteen out of them were novel variants (25.9%). Patients who complied with NIH criteria had most frequently frameshift variants (11/32 patients), and those with only CALMs had missense variants (9/28 patients). Neurofibromatosis type 1 bright objects (NBOs) on T2-weighted MRI were detected in 42 patients (42/56; 75%). These brain lesions were detected mostly in basal ganglia and in cerebellar vermis. NBOs were detected more in the patients who complied with NIH criteria (80.6%) compared to those who were only CALMs (68%). While frameshift variants (33.3%) were the most common type variants in the patients who had NBOs, the most common variants were splicing (35.7%) and missense (35.7%) variants in the patients whose MRIs were normal. Frameshift variants (11/28 patients; 39.3%) were the most common in the patients with more than one brain locus involvement. Therefore, we consider that frameshift variants may be associated with increased incidence of NBOs and involvement of more than one brain locus. In addition, NBOs may occur less frequently in the patients with splicing variants. To our knowledge, this is the first study evaluated the relationship between NF1 gene variants and NBOs. Future studies may help us understand the etiology of NBOs.

Ankle Joint Injuries Accompanying Fifth Metatarsal Base Fractures.

BACKGROUND: Fifth metatarsal base fractures are the most commonly seen fractures of the foot. Ankle sprains occur with inversion and plantarflexion mechanisms, similar to most fifth metatarsal base fractures. We sought to investigate the possible ankle injuries that accompany fifth metatarsal base fractures. METHODS: A hospital's digital database was searched for the International Classification of Diseases, Tenth Revision codes for metatarsal bone fractures (codes S92.30 and S92.35) between January 2015 and January 2018. Thirty-nine patients with fifth metatarsal base fracture who underwent ankle magnetic resonance imaging (MRI) within 14 days of injury were included in the study. The MRI findings were evaluated, and comparisons were performed according to fracture zone, sex, and age. RESULTS: The most common MRI finding was talocrural joint effusion, which was observed in 28 patients (71.8%). Bone marrow edema was observed in 16 patients (41.0%). Chondral injury at the medial dome of talus was observed in three patients (7.7%). Grade 1 ligament sprain was observed in six patients (15.4%): two in the lateral ligament and four in the deltoid ligament. CONCLUSIONS: Although most fifth metatarsal base fractures and ankle sprains occur as a result of a common mechanism, physical examination findings and patients' complaints are very important. Routine MRI should be unnecessary for most patients. If a patient with a fifth metatarsal base fracture has complaints about the ankle joint, one should be aware of bone marrow edema, which was observed in 41.0% of the study population.

The influence of anesthesia-body mass index and chronicity of the injury on the reliability of diagnostic tests for anterior cruciate ligament rupture.

This study aimed to analyze the accuracy and interobserver reliability of the four common diagnostic tests for anterior cruciate ligament (ACL) rupture. The effect of anesthesia, chronicity of the injury and patient's body mass index (BMI) on the reliabilities was also assessed. Patients who underwent arthroscopic knee surgery were examined before the surgery and under anesthesia by three observers categorized based on their experience levels. One hundred two patients were evaluated to determine the accuracy of these tests. Sixty-two patients with ACL rupture were further examined to assess the effect of BMI (≤25 kg/m2, or >25 kg/m2) and chronicity (≤4 or >4 weeks) of the injury on reliabilities with using the Fleiss kappa method. The Lachman test performed under anesthesia had the highest sensitivity (100%, 100%, and 96.7%). In contrast, pivot shift and lever sign tests had the lowest sensitivity both in awake (24.2%, 17.7%, 8.1% and 37.1%, 33.8%, 29%) and anesthetized condition (75.8%, 75.8%, 67.7% and 41.9%, 43.5%, 40.3%). Specificities of the tests except pivot shift were negatively affected when performed under anesthesia. The reliability of the anterior drawer test was perfect under anesthesia. The lever sign test had the highest reliability in the awake condition in patients with a BMI of >25 kg/m2. Furthermore, the reliabilities of the anterior drawer, Lachman, and pivot-shift tests in awake condition were found to be increased in patients with a chronic injury. Finally, the examiner's experience is not important for the physical diagnosis of ACL rupture.

Assessing the role of hip arthrography in the treatment decision making for children with Legg-Calvé-Perthes disease.

OBJECTIVE: The aim of this study was to determine the role of hip arthrography in the treatment decision making for children with Legg-Calvé-Perthes disease (LCPD). METHODS: A total of 47 consecutive children with LCPD (42 boys, 5 girls; mean age=7.5 years; range=6-10 years) who underwent operative treatment were included in the study. The patient demographics, physical examination findings (pain and hip range of motion [ROM]), standard anteroposterior and Löwenstein lateral hip radiographs, and hip arthrography data were retrospectively collected. The arthrographies were performed immediately before the surgery under general anesthesia. The patients were staged according to the Catterall and Herring classifications and examined in terms of head-at-risk signs before the study. Four sets of patient files were established based on the aforementioned data, with each child in a randomized and blinded order. Ten consultant pediatric orthopedic surgeons randomly assessed the patient files on 4 separate occasions (Set 1 vs Set 2 and Set 3 vs Set 4), with a minimum time interval of 4 weeks. In the first and second sets, the demographic and clinical information, including the age, gender, hip ROM, and hip radiographs, were presented. In the third and fourth sets, hip arthrography was presented in addition to the data from Set 1 and Set 2. The observers were instructed to choose the best treatment options. The percent agreement (PA) and Gwet's AC1 statistics were used to establish a relative level of agreement among the observers. RESULTS: The mean intra-observer reliabilities ranged from fair to moderate after adding the hip arthrography data (Gwet's AC1 = 0.36 for Set 1 vs Set 2 and 0.42 for Set 3 vs Set 4). The mean PA was 56.6% (range = 29.8% to 78.7%) with a Gwet's AC1 value of 0.51 (range: 0.21 to 0.77) between Set 1 and Set 3 (moderate intra-observer reliability). The decision for the treatment strategy was changed in 43.4% of the patients. For inter-observer reliability, Gwet's AC1 was computed as 0.48 (moderate reliability). The correlation between the intra-observer reliability and stage progression was not significant (p>0.05) for any of the subgroups. Thus, there is a negative correlation with the disease progression. CONCLUSION: Hip arthrography seems to have a significant role in the treatment decision making for children with LCPD, especially in the advanced stages of the disease. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Effect of COVID-19 pandemic on the fracture demographics: Data from a tertiary care hospital in Turkey.

OBJECTIVE: The purpose of this study was to evaluate the types and the frequency of fractures, both in the pediatric and adult population during the COVID-19 pandemic and to find out the differences in comparison to the non-pandemic period. METHODS: Patients who were admitted to the hospital with a new fracture during pandemic period (March 16 to May 22, 2020) were evaluated. Control group consisted of patients with new fractures admitted to the hospital in the same date range in 2018 and 2019. The patients were divided into two groups as ≤16 years old (group 1) and >16 years old (group 2). The evaluation was based on the age and gender of the patients and localization of the fractures. Hospitalized and surgically treated patients were evaluated as well. RESULTS: A total of 1794, 1747, and 670 fractures were observed in 2018, 2019, and 2020, respectively. Mean age of the patients in group 1 was found to have decreased in the pandemic period (p<0.001). The most common fracture sites in the pediatric population were the distal forearm and distal arm, whereas hand, distal forearm, and foot were most common fracture sites in adults, in both pandemic and non-pandemic periods. The proportional increase in femoral and tibial shaft fractures in group 1, and toe, tibial shaft, and metacarpal fractures in group 2 was found to be statistically significantly (p<0.05). In group 1; 6.8%, 7.7%, and 14.6% of the fractures were treated surgically in 2018, 2019, and 2020, respectively (p<0.001). For group 2, these rates were 20.1%, 18.6%, and 18.1%, respectively (p=0.67). There were 48, 29, and 26 open fractures in 2018, 2019 and 2020, respectively (p=0.066). In pandemic period, duration of the hospital stay was significantly shorter for distal humerus and proximal femur fractures (p values= 0.001 and 0.017, respectively). CONCLUSION: We observed that the frequency of fractures decreased by approximately one-third during the pandemic period compared with that in the non-pandemic period. The mean age of the patients with a fracture in the pediatric group was found to have decreased also. Finger fractures in pediatric patients and metatarsal fractures in adult patients were found to have significantly decreased during the pandemic. LEVEL OF EVIDENCE: Level III, Diagnostic study.

The Effect of Clinical Knowledge and Surgical Experience on Treatment Choice in Legg-Calve-Perthes Disease: Intra-observer and Inter-observer Reliability Study.

AIM: The aim of this study was to evaluate standardized hip radiographs, arthographs, demographic characteristics, physical examination findings, and their effects on treatment choices in leg-calve-perthes disease (LCPD). Intraobserver and interobserver realibility between orthopaedic residents, orthopaedic surgeons, and paediatric orthopaedic surgeons were also investigated. MATERIALS AND METHODS: 47 LCPD patients were included this cross-sectional study. Six separate presentations including different variabilities (clinical findings, standard radiographs, and arthrographs) were evaluated by three different groups (residents, surgeons, paediatric orthopaedic surgeons) and were sent to the observers every other month by hiding patients' personal information. Seven different treatment modalities were introduced for the best treatment modality. Intraobserver and interobserver reliability in these three groups were examined. Percentage aggreement (PA) and intraclass correlation coefficients (ICC) tests were used for this purpose. RESULTS: Treatment PA rates between presentations were 29.5-53.6% in residents, 38.3-60.4% in surgeons, and 39.1-59.8% in pediatric orthopaedic surgeons. Conservative methods were mostly preferred as treatment modality in all groups; followed by proximal femoral osteotomies. Pediatric orthopaedic surgeons preferred safe dislocation and femur head and/or neck reconstruction surgery 5-18 times more than residents and orthopaedic surgeons. Intraobserver reliability of treatment modalities was higher among the paediatric orthopaedic surgeons; the results were fair-good (0.483-0.763). Among residents and orthopaedic surgeons, ICC values were poor to good, respectively (- 0.080 to 0.636 and 0.263-0.643). Interobserver reliability among three groups was meanly good. CONCLUSION: As surgical experience increases, both the compliance rates of the treatment modalities and the intra- and inter-group reliability are increased. Knowledge of the demographic data and clinical findings of patients besides hip radiographs or arthrographs increase treatment compliance in paediatric orthopaedic surgeons, however, cause changes in treatment modalities in residents. As surgical experience increases, more difficult surgeries such as safe dislocation and femoral head/neck reconstruction are preferred.

Quantitative assessment of changes in lesser trochanter shapes in relation to femoral rotations.

OBJECTIVE: The aim of this study was to evaluate changes in lesser trochanter shapes in relation to femoral rotations and to develop a reference value for the determination of clinically relevant malrotation of the femur. METHODS: Patients who underwent computed tomography angiography between January 2009 and July 2018 were identified based on a review of their institutional medical records. Thereafter, three-dimensional (3D) images of the whole femur for a total of 860 patients were obtained from their tomographic sections. The distance between the lateral outer cortex of the femur and the most medial point of the lesser trochanter with the femur in neutral rotation was measured and set as the reference value. Then, the same distance was measured at 5°, 10°, 15°, and 20° of femoral internal rotation and at 5°, 10°, 15°, 20°, and 25° of femoral external rotation. To avoid magnification errors, the reference values were divided by each measured value at these different rotation angles and then multiplied by 100. RESULTS: The mean distances between the lateral cortex and the most medial point of the lesser trochanter at 5°, 10°, 15°, and 20° of femoral internal rotation were 97%, 93%, 90%, and 88%, respectively, of those measured with the femur in neutral rotation. The same distances at 5°, 10°, 15°, 20°, and 25° of femoral external rotation were 102%, 104%, 106%, 107%, and 108%, respectively, of those measured with the femur in neutral rotation. There was no statistically significant difference between the measured distances in males and females (p>0.05). However, significant differences were observed among each measured distance at different angles of femoral rotation (p<0.01). CONCLUSION: The surgeon should be aware of the possible femoral malrotation if the distance between the lateral cortex of the femur and the most medial point of the lesser trochanter on the operated side is more than 106% or less than 90% of that measured with the femur in neutral rotation on the healthy side. LEVEL OF EVIDENCE: Level IV, Diagnostic study.

Cornelia de Lange syndrome: A rare case, presented with unilateral pes equinovarus.

Cornelia de Lange syndrome is a genetic disorder with multiple system abnormalities. It is especially characterized by typical facial appearance and hirsutism. Growth and mental retardation, gastrointestinal, cardiovascular, and orthopedic abnormalities are other important features of this syndrome. In this case, we present a rare manifestation of Cornelia de Lange syndrome with a unilateral pes equinovarus deformity without other more specific orthopedic manifestations. Ponseti method's was applied as the initial procedure. Afterwards, complete subtalar release was performed. After four years follow-up, clinical and radiological results were satisfactory. Unilateral pes equinovarus deformity may be a part of this syndrome as well as a sporadic presentation. The discrimination is important for anesthetic procedures and surgical outcomes.

A New Reference to Evaluate Syndesmosis in Sagittal Plane Radiographs of the Ankle: The Lateral Posterior Ankle Ratio.

BACKGROUND: Confirmation of anatomical reduction of ankle syndesmosis is mandatory because improper reduction leads to poor functional results. Coronal plane evaluation of syndesmosis is well described in the literature, but there is little information about sagittal plane evaluation. We sought to evaluate the relationship of fibula and tibia in the sagittal plane and create a new reference that can be applied easily and reliably. METHODS: Lateral ankle radiographs of 337 individuals with no history of ankle fracture were evaluated. A line was drawn between the anterior and posterior cortices of the distal lateral tibia, and the length of this line was measured (line 1). The distance between the anterior and posterior cortices of the fibula on this line was measured, and the center of this second distance was identified and marked. The posterior half of the fibular width was divided by line 1 and was named the lateral posterior ankle ratio (LPAR). Statistical analysis was performed by side and sex. RESULTS: Mean patient age was 38.6 years; mean LPAR was 0.48. There was a significant difference between men and women by age (P < .001) and LPAR (P = .01). There was no significant difference between right and left ankles by age (P = .63) and LPAR (P = .64). The LPAR was less than 0.40 in 6.8% of the radiographs, 0.40 to 0.50 in 57.9%, and greater than 0.50 to 0.60 in 32.9%. CONCLUSIONS: The LPAR should approximate 50% in normal lateral ankle images and, by extrapolation, after syndesmotic reduction.

Langenskiöld Classification for Blount Disease: Is It Reliable?

BACKGROUNDS: Blount disease (BD) is a developmental disease which medial part of the proximal tibial physis resulting genu varum. Plain radiographs are necessary for diagnosis. For this purpose, Langenskiöld classification is used. There are not enough data about Langenskiöld classification's reliability in the English literature. The purpose of this study is to evaluate the intra- and inter-reliability of Langenskiöld classification in BD. MATERIALS AND METHODS: Thirty seven patients with BD were included in this cross-sectional study. Two separate presentations including clinical findings and standard knee radiographs were evaluated by three different groups (residents, surgeons, and pediatric orthopedic surgeons) and were sent to the observers every other month by hiding patients' personal information. Intraobserver and interobserver reliabilities in these three groups were examined. Intraclass correlation coefficient (ICC) tests were used for this purpose. RESULTS: Intraobserver reliability (ICC) was similar (excellent) in three groups (0.822, 0.804, and 0.763). Interobserver reliability among three groups was meanly excellent. CONCLUSION: Agreement to Langenskiöld classifications found excellent for three groups. Surgical experience did not change intraobserver and interobserver reliability in Langenskiöld classification.

Compartment syndrome secondary to Baker's cyst rupture: A case report and up-to-date review.

Baker's cyst is a distention or enlargement of the gastrocnemius-semimembranosus bursa toward the popliteal fossa which is usually associated with intra-articular pathologies. Rupture or dissection of the Baker's cyst results in extravasation of the cyst content into the calf within intermuscular space under the fascia. This clinical entity, also called pseudothrombophlebitis, is a self-limited condition that usually resolves with supportive treatment. However, in patients using anticoagulants, excessive hemorrhage may cause compartment syndrome in case of cyst rupture. Early diagnosis of compartment syndrome is the most important step in preventing permanent disability. Therefore, compartment syndrome should be kept in mind and ruled out in a patient with pseudothrombophlebitis syndrome under anticoagulation therapy.

Does anterolateral ligament rupture affect functional outcomes in patients who underwent an anterior cruciate ligament reconstruction?

BACKGROUND: Studies have shown that the anterolateral ligament contributes to knee stability. This study aims to compare the results of postoperative physical examinations, knee joint stability tests, and functional assessment tests of patients with intact anterolateral (AL) ligaments and patients with ruptured anterolateral (AL) ligaments. MATERIAL AND METHOD: This study consisted of 101 patients, with at least a 12-month follow-up period, who underwent an anterior cruciate ligament reconstruction between 2010 and 2016, and whose AL ligaments were evaluated by the radiologist with the preoperative and postoperative magnetic resonance images (MRI). Of these patients, 41 had intact AL ligament (Group 1) in MRI and other 60 had ruptured AL ligament (Group 2). Groups were compared according to postoperative physical examinations, knee joint stability tests, and functional assessment tests. RESULTS: The average Lysholm score of Group 1 was 94.9 (range: 81-100), and the score of Group 2 was 87.2 (range: 74-100). The modified Cincinnati score of Group 1 was 28.7 (24-30), while the score of Group 2 was 25.6 (21-30). The average IKDC subjective knee evaluation score of Group 1 was 91.9 (range: 83-100), and the score of Group 2 was 86.6 (range: 75-100). The average thigh atrophy value was 1.5 centimeters (cm) in Group 1 and 2.4 cm in Group 2. Thirty-three patients in Group 1 were able to jump over 85% of the distance in single-legged hop test compared to the intact side, while 16 patients in Group 2 were able to jump over this distance successfully. As a result of the analysis, it was determined that the Lysholm activity scoring results, the Modified Cincinnati scoring results, IKDC subjective knee evaluation results, two-cycle IKDC activity scale results, comparison of thigh diameters and the single-legged hop tests of two groups showed a statistically significant difference, and the results of the patients with intact AL ligaments who underwent an ACL reconstruction were found to be better (p < 0.05). No significant difference was found in other examinations and tests. CONCLUSION: Since the rupture of the AL ligament has negative effects on functional outcomes, we think that the reconstruction of the AL ligament in the same session with the ACL reconstruction or later will have a positive effect on functional outcomes.