Late-diagnosed bilateral intertrochanteric femur fracture during an epileptic seizure.

Although spontaneous and simultaneous bilateral hip fractures without trauma are seen rarely, epileptic seizures may lead to these fractures. We present an 82-year-old female patient with poor bone quality and a 20-year history of epilepsy. She had been using anticonvulsant drugs for almost 20 years. Following a convulsive epileptic attack, bilateral intertrochanteric femur fractures occurred (causing bilateral hip pain), which was diagnosed on the 12th day. An earlier pelvic anteroposterior roentgenogram would be helpful for early diagnosis. It should not be forgotten that bone fractures may be observed without trauma in epilepsy patients.

Acute stress disorder and post-traumatic stress disorder following traumatic amputation.

Traumatic amputations are important causes of acute stress disorder and post-traumatic stress disorder. In this study, we aimed to find out the occurrence rate of symptoms of acute and post-traumatic stress disorder after traumatic amputations and according to this, to assess the psychiatric status of the patients in the postoperative period. Twenty-two patients with traumatic limb amputation who were treated in our institution were retrospectively evaluated. During the early post-traumatic period, the patients were observed to determine whether they needed any psychiatric supportive treatment. During the follow-up period, after the sixth month from the trauma, the patients were referred to the psychiatry department and they were evaluated to determine whether they needed any psychiatric supportive treatment, by clinical psychiatric examination and use of the 'post-traumatic stress disorder scale' (Clinician Administered Post traumatic Scale, or CAPS). Twenty-one (95.5%) of 22 patients were male, one (4.5%) female. Mean age of the patients was 40.8 years (range: 15 to 69). During the early posttraumatic period, 8 (36.3%) of these patients consulted the psychiatry clinic following the orthopaedists' observations. Five (22.7%) of these patients needed psychiatric supportive treatment for acute stress disorder. After the 6th month (6 months to 5 years), 17 (77.2%) had chronic and delayed post-traumatic stress disorder and needed psychiatric supportive treatment. Patients who have sustained a traumatic amputation may need psychiatric supportive treatment in the late period after the trauma. As we orthopaedic surgeons treat these patients surgically, we should be aware of their psychiatric status.

Osteosarcoma of the lumbar vertebra: case report and a review of the literature: rare localization with long survival.

Classic osteosarcoma (OS) is a highly malignant sarcoma with the production of osteoid matrix. The most common sites of origin are the metaphyseal regions of the distal femur, proximal tibia, and proximal humerus, although the tumor can develop in any bone. Flat bone involvement is very rare (8%). Vertebral involvement is also very rare with 2-4% of all cases. In this report, we presented a 27-year-old woman with OS of the fourth lumbar vertebra. She was treated with surgical debulking and posterior enstrumentation, followed by radiotherapy and chemotherapy. She is now in the 15th year postoperatively and still alive without any neurological impairment. This case has the longest survival reported in the literature with primary vertebral osteosarcoma.

[Functional results of patients treated with modular prosthetic replacement for bone tumors of the extremities]. / Tümör rezeksiyon protezi uygulanan kemik tümörlü olgularda fonksiyonel sonuçlar.

OBJECTIVES: We evaluated functional results of patients who were treated with cemented modular prosthetic replacement for bone tumors of the extremities. METHODS: The study included 23 patients (12 males, 11 females; mean age 49 years; range 14 to 81 years) who underwent wide resection and cemented endoprosthetic replacement with the TMTS (Turkish Musculoskeletal Tumor Society) prosthesis for bone tumors. Twelve patients (52.2%; mean age 63.5 years) had metastatic, 11 patients (47.8%; mean age 38 years) had primary tumors. The most common site of involvement was the femur (n=17), followed by the humerus (n=5). Functional evaluations were made with the Musculoskeletal Tumor Society (MSTS) scoring system. The mean follow-up period was 24 months (range 1 to 108 months), being 30 months for primary, and 3 months for metastatic tumors. RESULTS: Postoperative complications were seen in seven patients (30.4%), being local recurrences in three patients. During the follow-up period, 11 patients died due to tumoral causes, distant metastasis developed in three patients, and nine patients were tumor-free. Survival was significantly better in patients with primary tumors (p<0.001). All the patients were able to walk without crutches in the postoperative period. The mean MSTS score was 58.9% (range 40% to 90%) in survivors, which was 71.5% (range 60% to 90%) for primary tumors, and 47.4% (range 40% to 73%) for metastatic tumors (p<0.001). CONCLUSION: Reconstruction with cemented modular endoprostheses is an appropriate surgical alternative in the treatment of large segmental defects after resection of extremity tumors, with satisfactory functional results particularly in primary tumors.

[Injuries associated with motorcycle accidents]. / Motosiklet kazalarina bagli yaralanmalar.

OBJECTIVES: In recent years, there has been a significant increase in motorcycle accidents in parallel with the increasing number of motorcyclists. Data on motorcycle accidents/injuries are relatively limited in Turkey. This study sought to determine the injury profile of patients involved in motorcycle accidents. METHODS: This retrospective study included 212 patients (204 males, 8 females; mean age 36+/-16 years; range 2 to 79 years) who were hospitalized for injuries caused by motorcycle accidents. Data on age and sex, injury patterns, length of hospitalization were recorded. Injuries were grouped according to localization. RESULTS: The frequencies of injuries in descending order were as follows: musculoskeletal system injuries (n=106, 50%), skull injuries (n=103, 48.6%), maxillofacial injuries (n=38, 17.9%), thoracic (n=15, 7.1%), vertebral (n=10, 4.7%), and abdominal (n=6, 2.8%) injuries. Multiple fractures in upper and lower extremities were seen in 17 (8%) and 43 (20.3%) patients, respectively. The most frequent extremity injuries were tibia-fibula fractures (17.9%) followed by shoulder injuries (11.3%). Both extremity and skull injuries were seen in 23 patients (10.9%). The mean hospital stay was 12.2+/-16.8 days (range 1 to 150 days). Eight patients required intensive care for a mean of seven days. As a complication, one patient (0.5%) with olecranon and tibial plateau fractures developed pulmonary embolism. Motorcycle accidents resulted in mortality in nine patients (4.3%). CONCLUSION: Since motorcycle accidents are preventable or associated risks for injuries are reducible, risk factors for our country should be determined, necessary laws and restrictive regulations should be put into practice, and educational programs should be implemented.

[An analysis of genetic transmission in a father and son with osteosarcoma]. / Osteosarkomlu baba ve ogulda genetik geçisin irdelenmesi.

Familial osteosarcoma is a rare hereditary disease. We present a 37-year-old father and a 17-year-old son who developed osteosarcoma in the left and right distal femurs, respectively, at a three-year interval. They were treated with chemotherapy followed by surgery. Both had positive immunostaining for p53 tumor suppressor gene and HER-2/neu oncogene. The son also exhibited deletion of the retinoblastoma 1 gene. Pulmonary metastasis was detected in the father at the time of diagnosis and 13 months after primary treatment, whereas no distant metastasis was present in the child. The father died 39 months after the diagnosis from primary symptoms, but the son led a disease-free survival a year after completion of treatment. Genetic abnormalities documented in the father and son corroborate the presence of specific genetic alterations in the pathogenesis of osteosarcoma.

Tumors of the spine.

Spine tumors comprise a small percentage of reasons for back pain and other symptoms originating in the spine. The majority of the tumors involving the spinal column are metastases of visceral organ cancers which are mostly seen in older patients. Primary musculoskeletal system sarcomas involving the spinal column are rare. Benign tumors and tumor-like lesions of the musculoskeletal system are mostly seen in young patients and often cause instability and canal compromise. Optimal diagnosis and treatment of spine tumors require a multidisciplinary approach and thorough knowledge of both spine surgery and musculoskeletal tumor surgery. Either primary or metastatic tumors involving the spine are demanding problems in terms of diagnosis and treatment. Spinal instability and neurological compromise are the main and critical problems in patients with tumors of the spinal column. In the past, only a few treatment options aiming short-term control were available for treatment of primary and metastatic spine tumors. Spine surgeons adapted their approach for spine tumors according to orthopaedic oncologic principles in the last 20 years. Advances in imaging, surgical techniques and implant technology resulted in better diagnosis and surgical treatment options, especially for primary tumors. Also, modern chemotherapy drugs and regimens with new radiotherapy and radiosurgery options caused moderate to long-term local and systemic control for even primary sarcomas involving the spinal column.

Subdural and cerebellar hematomas which developed after spinal surgery: a case report and review of the literature.

Cerebellar hemorrhage following a spinal surgery is extremely rare; however, considering the localization, it can cause major clinical manifestations. While it is considered that these types of bleedings occur secondary to a venous infarct, the pathogenesis is still unclear. A 57-year-old male patient who underwent a laminectomy by exposing T12-L5 and had pedicle screws placed for ankylosing spondylitis developed a CSF leak due to a 2 mm dural tear. A hemorrhage with parallel streaks on the left cerebellar hemisphere was seen in CT scan, and a thin subdural hematoma at right frontotemporal region was seen on cranial MRI, performed after the patient developed intense headache, nausea, vomiting, and stiff neck in the early postoperative period. In this paper, a case of cerebellar and subdural hematomas following a spinal surgery is discussed with its clinical and radiologic findings.

Non-operative treatment in children and adolescents with atlantoaxial rotatory subluxation.

OBJECTIVE: Atlantoaxial rotatory subluxation (AARS) is an uncommon lesion seen mainly in children and adolescents. A retrospective analysis of 12 patients with AARS treated non-operatively is presented in this study. MATERIAL AND METHODS: Twelve patients with AARS who were treated non-operatively were evaluated retrospectively in terms of recent trauma and respiratory tract infection history, accompanying injuries, radiological findings, duration of symptoms, amount and duration of traction and clinical results of the treatment. RESULTS: Traumatic AARS was present in 8 patients. No evidence of trauma was found in 4 patients. Type I subluxations in 10 and type II subluxations in 2 patients were found according to the Fielding and Hawkins classification. All patients were treated using bed-side mentooccipital tractions. The mean duration of bed-side mentooccipital traction was 3,75 days and the mean amount of load was 1.8 kg. All patients were kept in Philadelphia collars for additional 3 weeks after the clinical recovery. No limitations and pain in head movements were present in any patient at the sixth month follow-up examinations. CONCLUSION: Paediatric patients with neck pain and torticollis should be investigated concerning trauma and recent respiratory tract infection history in order to avoid any delay in diagnosis of a possible AARS.

Magnetic resonance imaging predictors of surgical outcome in degenerative lumbar spinal stenosis.

PURPOSE: To identify any MRI predictors for surgical outcomes of patients with degenerative lumbar spinal stenosis (DLSS) having instrumented posterior decompression (IPD) surgery. MATERIALS AND METHODS: Seventy patients with DLSS who underwent IPD were reviewed retrospectively. The clinical score of each patient was assessed using the JOAS (Japanese Orthopedics Association Scoring) system, which is mainly based on the subjective symptoms and physical signs of the patients before (JOAS-I) and after (JOAS-II) surgery. Healing rate (HR) was calculated as: [(JOAS-II) - (JOAS-I)] × 100/[15 - (JOAS-I)]. HR >50 % was considered clinical improvement. Radiological stenosis was assessed on MRI and was graded from 0 to 3 at the laminectomy level in terms of thecal sac-nerve root compression, foraminal stenosis, and facet degeneration. RESULTS: Mean HR of the improved patients (n = 39) was 81.94; HR of the unimproved patients (n = 31) was 34.75 (p < 0.05). There was no statistical difference in radiological stenosis parameters between the two groups (p > 0.05). HR was worse in patients with severe facet degeneration. CONCLUSIONS: Surgical outcomes of DLSS depend on multiple variables. It is not possible to predict the outcomes by assessing only one parameter. The possible outcomes should be analyzed by considering all the factors individually.

Postoperative evaluation of quality of life in lumbar spinal stenosis patients following instrumented posterior decompression.

OBJECTIVES: Spinal stenosis is a clinical condition in which bone and soft tissues compress the spinal canal, neuronal foramina and nerve roots. In this study, we aimed to evaluate the effectiveness of surgical treatment on patient satisfaction. Our sample included 64 patients with degenerative lumbar spinal stenosis on whom posterior decompression and instrumentation was applied. METHODS: In this retrospective study, files of 64 patients who underwent posterior decompression surgery with instrumentation for degenerative lumbar spinal stenosis between March 2004 and April 2008 were examined. Patients were evaluated with Japanese Orthopaedic Association (JOA) form, form of degenerative lumbar spinal stenosis and the most recent postoperative orthopedic inspection findings for a minimum of one year after surgery. RESULTS: Mean age of patients was 59.9 years and mean follow-up was 27.9 months. When evaluated using the Japanese Orthopaedic Association form, postoperative scores in 63.5% of the patients improved. Based on this postoperative improvement; Japanese Orthopaedic Association scores were found statistically significant (p<0.001). Gender (p=0.651), age (p=0.192), with the length of complaint (p=0.095), time passed after surgery (p=0.933), number of laminectomy level (p=0.997), deformity before operation (p=0.773) and systemic disease were not statistically correlated with improvement based upon Japanese Orthopaedic Association scores (p=0.052). But Japanese Orthopaedic Association scores were found to have improved (83%) in cases with no systemic diseases. CONCLUSION: Our findings show that posterior decompression surgery with instrumentation is a useful treatment modality for patients with severe degenerative lumbar spinal stenosis. There is no secondary factor affecting improvement and instability after surgery is not observed in patient groups.

Comparison of autogenous bone graft donor site haemostatic agents used in spinal surgery.

OBJECTIVE: The aim of our study was to investigate the effects of haemostatic agents used at the autograft donor sites in spinal fusion. METHODS: The study included 66 patients (26 men, 40 women; mean age: 42.9 years) who underwent spinal fusion surgery between March 1999 and October 2002. Patients were randomly assigned to 4 different groups according to the haemostatic agents used during surgery. In Group 1, bone wax was used on the graft donor site. In Group 2, spongostan was used. In Group 3, spongostan was applied to the donor site and removed after 10 minutes. Group 4 was the control group and no haemostatic agent was applied. Age, sex, diagnosis and incision shape were not taken into consideration during the selection of patient groups. Closed suction drainage systems were used for the evaluation of drainage amount. The drainage system was removed after 48 hours in patients with a daily drainage of less than 30 cc. RESULTS: In Group 1, there was significantly less drainage than the other groups. Group 2 and Group 3 had less drainage than the control group. When a separate incision was used for graft harvesting, keeping the spongostan at the application site (Group 2) was more effective than its removal (Group 3). CONCLUSION: The application of bone wax and spongostan to bleeding cancellous bone surfaces at the donor site is a safe and effective method to reduce bleeding and hematoma. Bone wax is more effective than spongostan for haemostasis.

[The safety of pedicle screw fixation in the thoracic spine]. / Torakal omurgada pedikül vidasi ile tespitin güvenilirligi.

OBJECTIVES: Thoracic pedicle screw fixation has many advantages over other methods of spinal fixation in treating various conditions. We evaluated the safety and efficacy of pedicle screw fixation in the thoracic spine. METHODS: We retrospectively reviewed 144 patients (65 males, 79 females; mean age 38 years; range 9 to 82 years) who underwent posterior thoracic pedicle screw instrumentation. A total of 827 thoracic pedicle screws were inserted to the thoracic spine (T1-12) by the same senior spine surgeon using the free-hand technique. Indications for thoracic spine surgery were deformities (n=47, 32.6%), metastatic or primary tumors (n=15, 10.4%), spinal infections (n=7, 4.9%), degenerative diseases (n=13, 9%), and spinal trauma (n=62, 43.1%). Screw containment was assessed by three independent reviewers on postoperative plain radiographs. In addition, thin-slice computed tomography scans were obtained in 21 suspected cases (29 screws). RESULTS: Screw containment was found in 94.3% (780 screws). Incorrect screw placement was found in 47 screws (5.7%), including 31 screws (3.8%) demonstrated by plain radiographs, and 16 screws (1.9%) demonstrated by thin-slice computed tomography scans. More than half of the faulty screws (n=24, 51.1%) were detected in scoliosis patients, especially on the concave side of the curvature (83.3%). The most frequent site of faulty screw placement was the T8 level (21.3%). No symptoms or complications occurred related to faulty screw placement. CONCLUSION: The high accuracy of thoracic pedicle screw placement (94.3%) using the free-hand technique suggests that pedicle screw fixation of the thoracic spine is safe, reliable, and useful in the treatment of all types of spinal diseases.

[Isolated synovial chondromatosis of the proximal tibiofibular joint]. / Proksimal tibiofibular eklemde izole sinovyal kondromatozis.

Synovial chondromatosis is a chronic, progressive disease of the synovial tissue where free chondral loose bodies are formed after metaplasia. It is mostly seen as a monoarticular disease in the knee, hip, shoulder, ankle, and elbow joints. To our knowledge, isolated synovial chondromatosis of the proximal tibiofibular joint has not been reported. A 36-year-old male patient presented with a complaint of pain on the lateral side of the right knee, whose severity gradually increased within the past two years. Radiological findings were suggestive of synovial chondromatosis of the proximal tibiofibular joint. The patient was treated with resection of the fibular head, including the satellite lesions. Histopathological examination confirmed the diagnosis. At one-year follow-up, the patient was symptomless, had full range of motion of the knee without pain, and had no problems in maintaining daily activities. Pathologies of the proximal tibiofibular joint must be kept in mind in patients with lateral knee pain.

Traumatic Hemipelvectomy: A Case Report and a Review of the Literature.

Traumatic hemipelvectomy is a life threatening, devastating pelvic injury with very low survival rates. Excessive loss of blood, related systemic problems and additional injuries about the gastrointestinal and genitourinary systems increase mortality of this severe sort of injury. A young, male farmer injured violently by an agricultural heavy machine; a survivor of traumatic hemipelvectomy is described in this case report.