Painful transient edema in the tibial diaphysis: the challenges and the essence of biopsy in treatment.

BACKGROUND: Some patients experience a non-traumatic pain in the tibial diaphysis similar to that in the clinical and radiological findings of a tumor, an infection or a stress fracture and cannot be definitively diagnosed even after biopsy. In this study, our aim was to exhibit the challenges in the diagnosis of this patient group and to evaluate this type of patients with a limited population in the literature. METHODS: Eighteen extremities of 16 patients, whose complaints of non-traumatic pain in the tibial diaphysis were evaluated by our tumor council and T2-weighted MR scans of the medullary bone had shown hyperintense signal changes or tumor-like appearances, were evaluated with histological, radiological, and clinical results. RESULTS: Lesions were detected in 18 extremities of the 16 patients (seven males, nine females; mean age 23 [range 7 to 51] years). Four of the lesions were in the right tibial diaphysis, ten were in the left, and two were bilateral. Laboratory findings of the patients were normal. Based on the decision of the tumor council, biopsy was performed on 12 patients. All patients' complaints were gone and MRI findings decreased during the follow-up period. The complaints of the three patients who did not have a biopsy decreased after a mean period of three months. CONCLUSIONS: Medullary stress syndrome has been reported in the literature in various forms and in a limited number of cases, including longitudinal stress fracture and transient medullary edema of the bone. In light of our findings, we deduced that biopsy of the diaphyseal lesions in this patient group is essential and that the complaints of this patient group declined in the earlier term in comparison to the patients who were not performed biopsy.

Tibial tubercle-trochlear groove distance and angle are higher in children with patellar instability.

PURPOSE: The purpose of this study was to assess the variations in tibial tubercle-trochlear groove distance and angle as a function of age and gender in a population of children without patellar instability (PI) compared with those with PI. METHODS: A retrospective review of 869 children's knee MRIs, ages 5 to 15 years, were evaluated using a control group (792 children) without evidence of PI and a group with PI (77 children). Tibial tubercle-trochlear groove distance (TT-TGd) and angle (TT-TGa) were measured twice by two readers to assess intra- and inter-observer reliability and compared between PI and control groups. In both groups, functions of age and gender on TT-TGd and TT-TGa values were evaluated. RESULTS: Both TT-TGd and TT-TGa measurements showed excellent intra- and inter-observer reliability. The mean TT-TGd for the PI group was 17.2 mm (SD 6.6) and significantly higher than the mean TT-TGd for the control group (10.4 SD 3.8 mm, P = 0.001). The mean TT-TGa for the PI was 20.8° (SD 8.3°), which was also significantly higher than the mean TT-TGa for the control group (12.5° SD 4.6°, P < 0.001). Control group revealed a positive correlation between age and TT-TGd measurements (r = 0.243, P < 0.001). The mean TT-TGa for girls (13.3° SD 4.7°) was higher than the mean TT-TGa for boys (11.9° SD 4.4°) in the control group (P < 0.001). CONCLUSION: TT-TGa and TT-TGd are reliable and can be used for the evaluation of the extansor mechanism alignment in children with and without PI. However, it must be considered that TT-TGd is increasing in growing patients. Soft-tissue procedures may be prone to failure, since bony procedures for patellar alignment cannot be done until skeletal maturity. LEVEL OF EVIDENCE: III.

Comparative Results of External Fixation, Plating, or Nonoperative Management for Diaphyseal Clavicle Fractures.

OBJECTIVE: The aim of this study was to compare the treatment outcomes of mid-diaphyseal clavicular fractures between an external fixator and more widely selected treatment options such as plate osteosynthesis or conservative methods. MATERIALS AND METHODS: The medical records of 64 patients who were treated for mid-diaphyseal clavicular fracture in our clinic from 2009 to 2013 were reviewed. The inclusion criterion was mid-diaphyseal closed clavicular fractures with shortening of more than 2 cm. The Constant and DASH (disabilities of the arm, shoulder, and hand) scores at the final follow-up, initial displacement, nonunion, and complication rates were compared. Statistical differences between groups were assessed with the Kruskal-Wallis test, and pairwise comparison analysis was used to evaluate the differences within the groups. RESULTS: Of the 64 patients, 24 (37.5%) were treated with plate osteosynthesis (group 1), 11 (17.2%) with an external fixator (group 2), and 29 (45.3%) conservatively with a figure-of-eight bandage (group 3). The mean follow-up periods were as follows: group 1: 37 ± 10.4 months, group 2: 33 ± 7 months, and group 3: 35 ± 9.4 months. The initial amount of displacement and DASH score were: group 1: 89.1 ± 7.8, group 2: 89.1 ± 7.8, and group 3: 6.1 ± 6.6) (p = 0.079). The Constant score of group 2 (93 ± 6.1) was significantly higher than that of group 3 (85 ± 8.4) (p = 0.013). No statistical difference was found in the distribution of nonunions (p = 0.387). However, in group 3, the number of malunions (11/29, 37.9%) was significantly higher compared to the other 2 groups (group 1: 1/24, 4.2%; group 2: 2/11, 18.2%) (p = 0.006). CONCLUSIONS: This study revealed that the treatment of acute clavicular fractures with an external fixator was a good alternative to plate osteosynthesis or conservative treatment.

Effect of the Presence of Subchondral Cysts on Treatment Results of Autologous Osteochondral Graft Transfer in Osteochondral Lesions of the Talus.

The aim of the present study was to clinically evaluate whether the presence of subchondral cysts had an effect on the treatment results of autologous osteochondral graft transfer in osteochondral lesions of the talus. Patients were enrolled in the present study according to the inclusion criteria. In the evaluation, we divided the patients into 2 groups according to presence (n = 13 patients) or absence (n = 15 patients) of a subchondral cyst. The mean age, body mass index, follow-up period, and lesion size in each group were measured and compared, and no statistically significant differences were found between the 2 groups (p > .05). The clinical assessment was performed using the American Orthopaedic Foot and Ankle Society Hindfoot scoring system, visual analog scale, and International Knee Society scoring system. No statistically significant difference was found between the pre- and postoperative scores of the 2 patient groups (p > .05). The successful results in both groups after a 2-year follow-up period have demonstrated that treatment of osteochondral lesions of the talus with osteochondral graft transfer is a safe method that can be performed independently of the presence of a subchondral cyst.

What Would be the Difference Between Operative Treatment of Patients with Tibia Fractures out of Working Hours; Intramedullary Nailing for Tibial Shaft Fractures.

Objectives: Performing orthopedic surgery in and out of working hours may affect the success of the surgery. Timing of surgery in tibial shaft fractures is controversial. In this study, the effect of the timing of surgery on the success and complications of intramedullary nailing of tibial fractures is examined. Methods: Archieves of patients with tibial shaft fractures treated with reamed intramedullary nails between 2010 and 2016 were retrospectively analyzed. Fifty-seven patients were included in the study. Patients were categorized by the time of the surgery. Day time (Group I) is between 7:00 am and 5:00 pm and after hour (Group II) is between 5:00 pm and 07:00 am. Group I (n: 40) and Group II (n: 17) were evaluated. Technical errors, surgery time, and length of hospital stay statistical analysis was performed between the two groups in terms of technical errors, complication rates, length of hospital stay, and duration of surgery. Results: The mean duration of operation (p=0.419), number of distal screws (p=0.847), time to union (p=0.454), experience of the surgeon (p=0.192), and technical error rate (p=0.654) did not differ significantly between two groups. Length of hospital stay and time to surgery from emergency were significantly higher in day time group. Conclusion: Technical errors and surgery time of intramedullary nailing of tibial shaft fractures are not higher at after hour before midnight than day time. Non-urgent tibial shaft fractures might be treated with intramedullary nailing at after hours before midnight for efficient use of hospitals.

A Modification of Internal Bone Transport Method for Reconstruction of Nonunion of Forearm.

BACKGROUND: Defects of bone and soft tissue occur frequently after high-energy trauma, infections, and tumor resection. Treatment options are limited and outcomes are controversial in nonunion. Classical reconstruction methods are challenging. We describe a method of internal bone transport for treatment of complicated nonunion of the forearm. This method permits axial and internal bone transport without harming the distorted and complex neurovascular anatomy or soft-tissue envelope. MATERIALS AND METHODS: Five patients (mean age, 27 years) with defect nonunion (3 ulna, 2 radius) were treated. Mean preoperative defect size was 36 mm, mean shortening was 14 (0-30) mm, and the extent of surgical resection was 24 (20-40) mm. Total bone loss due to defect, resection, or shortening was 74 mm. According to Paley classification, two of the patients had B1, and three had B3 defect nonunion. This study treats defect nonunion of the forearm using an internal bone-transport method. Our method involved cannulated screws, a cerclage wire, and a circular fixator being used in combination. When transportation was completed, internal fixation of the docking site with a plate and screws was done, with bone grafting after fixator removal. Bone healing and functional outcomes were assessed with radiographs and disabilities of the arm, shoulder, and hand (DASH) scores, respectively. RESULTS: Mean followup was 67.6 months. Solid osseous union and functional improvement were achieved in all cases. Mean bone loss was 66 mm, mean fixator time was 131.8 days, the lengthening index was 1.3 days/mm, and the fixator index was 2.1 days/mm. DASH score was 82.2 before treatment and 15.36 after treatment. CONCLUSIONS: Using our method, internal bone transport and progressive axial docking of defects can be done with minimal effects on surrounding neurovascular arrangements and soft tissues. Size of fixators can be decreased and formation of painful scar tissue can be avoided.

Simultaneous bilateral correction of genu varum with Smart frame.

PURPOSE: The aim of this study is to evaluate clinical and radiological results of simultaneous bilateral correction of genu varum with Smart frame. METHODS: Between 2011 and 2015, a total of 25 patients (10 females, 15 males) who had bilateral genu varum deformity were operated bilaterally with tibial and fibular osteotomy in the same session, using Smart frame. The mean follow-up period was 28.7 (range, 13-45) months. All patients had bilateral tibial varus deformity. Femoral deformity was corrected in an earlier session in nine patients. Mechanical axis deviation (MAD), mechanical lateral distal femoral angle, mechanical medial proximal tibial angle (mMPTA) and posterior proximal tibial angle (PPTA) were measured preoperatively and postoperatively. Short Form-36 questionnaire was filled by the patients preoperatively and during the last follow-up. RESULTS: The mean preoperative MAD was 37.6 mm (range, 9-98 mm), which improved to 8.4 mm (range, 3-44 mm) postoperatively ( p < 0.05). The mean preoperative mMPTA was 76°, which improved to 89° ( p < 0.05). The mean preoperative PPTA was 75.5°, which improved to 80.3 ( p < 0.05). Ten problems (20%), two obstacles (4%) and no sequelae occurred in 50 legs of 25 patients. CONCLUSIONS: In conclusion, Smart frame is an accurate and reliable method for performing bilateral simultaneous deformity correction in patients with bilateral genu varum deformity. It can be applied for various childhood-induced severe tibial deformities such as achondroplasia, rickets, skeletal dysplasia and Blount's disease.

Factors affecting results of fluoroscopy-guided facet joint injection: Probable differences in the outcome of treatment between pure facet joint hypertrophy and concomitant diseases.

STUDY DESIGN: Retrospective cohort study. PURPOSE: Facet joints are considered a common source of chronic low-back pain. To determine whether pathogens related to the facet joint arthritis have any effect on treatment failure. MATERIALS AND METHODS: Facet joint injection was applied to 94 patients treated at our hospital between 2011 and 2012 (mean age 59.5 years; 80 women and 14 men). For the purpose of analysis, the patients were divided into two groups. Patients who only had facet hypertrophy were placed in group A (47 patients, 41 women and 6 men, mean age 55.3 years) and patients who had any additional major pathology to facet hypertrophy were placed in group B (47 patients, 39 women and 8 men, mean age 58.9 years). Injections were applied around the facet joint under surgical conditions utilizing fluoroscopy device guidance. A mixture of methylprednisolone and lidocaine was used as the injection ingredient. RESULTS: In terms of Oswestry Disability Index (ODI) and visual analog scale (VAS) scores, no significant difference was found between preinjection and immediate postinjection values in both groups, and the scores of group A patients were significantly lower (P < 0.005) compared with that of group B patients at the end of the third, sixth, and twelfth month. CONCLUSION: For low-back pain caused by facet hypertrophy, steroid injection around the facet joint is an effective treatment, but if there is an existing major pathology, it is not as effective.

Chevron osteotomy in patients with scheduled osteotomy of the medial malleolus.

OBJECTIVE: The aim of the present study was to evaluate intermediate-term outcomes of Chevron osteotomy for treatment of osteochondral lesions of the talus with mosaicplasty and to assess its effect on surgery and whether it reduces complications that might occur intraoperatively. METHODS: The present study included a total of 42 patients (31 men, 11 women) who underwent Chevron osteotomy of the medial malleolus and who had been followed for more than 2 years. Mean age of the patients was 34 years (range: 18-54 years). Preoperatively, size of the lesions was measured in millimeters in the coronal and sagittal planes using magnetic resonance imaging (MRI). The angle between the osteotomy with the long axis of the tibia was measured on the coronal plane, the angle between the arms and the angle for the screws to be directed to the osteotomy line were measured on the sagittal plane on the postoperative images. Nonunion, malunion, and complications from the screws were evaluated from X-ray images taken at the final follow-up. RESULTS: Mean duration for follow-up was 31.4 years (range: 24-46). On the X-ray images taken at the final follow-up, no distraction, migration of the distal part, or rotation was observed. Only 1 patient experienced radiological non-union. Mean duration to union was 5.8 weeks (range: 4-14 weeks). Screws of 8 patients were removed at an average of 7.4 months (range: 5-11 months). The angle between the osteotomy line and long axis of the tibia was 29.0°±6.5°, the angel between the osteotomy arms on the sagittal plane was 74.7°±8.3°, and the direction angle of the screws on the coronal plane was 85.7°±5.9°. CONCLUSION: Chevron osteotomy is an assistive surgical method used for treatment of osteochondral lesions located in the medial talar joint surface (TOL) which provides fast anatomical healing because it allows efficient fixation due to its geometry.