Is There a Chance to Treat Modified Gartland Type IIB Pediatric Supracondylar Humerus Fractures With Closed Reduction and Casting?

BACKGROUND: Wilkins modification of the Gartland classification (WMGC) type IIB supracondylar humeral fractures (SCHFs) are unstable, and their primary treatment is surgery. This study sought to evaluate the chance of closed reduction and long arm cast (CR&LAC) treatment of type IIB fractures. METHODS: In this retrospective case-control study, pediatric patients with WMGC type II fractures whose initial treatment was CR&LAC were examined. Cases were subdivided according to WMGC. Type IIA and IIB cases were compared in terms of the reduction loss rate and clinical and radiologic results. Then, patients with type IIB fractures who were treated conservatively or surgically were compared in terms of clinical and radiologic results. RESULTS: A total of 817 pediatric SCHFs were examined, of which 233 had type II fractures. This study finally enrolled 87 cases who met the inclusion criteria, including 52 with type IIA fractures and 35 with type IIB fractures. Among those with type IIB fractures, the first-time reduction success rate was 44.3%. Although the probability of a loss of reduction among type IIB fractures in conservative follow-up was ~5 times higher than that among type IIA fractures, all the cases with reduction loss were detected among the first-week controls, and 9 of them were type IIB and 3 were type IIA ( P =0.011). The treatment of 26 (32.9%) cases with type IIB fractures was completed conservatively. There was no difference in the clinical or radiologic comparison results of type IIA and type IIB fractures whose treatment was completed conservatively. There was no clinical or radiologic difference in the comparison of type IIB fractures whose treatment began with CR&LAC but was completed conservatively or surgically. CONCLUSIONS: Although the initial reduction success is not high among WMGC type IIB fractures, the results are like those of conservatively managed type IIA fractures if successful reduction is achieved. This study showed that the treatment results of all type II SCHFs with no loss of reduction in the first week after CR&LAC are satisfactory. No reduction loss was observed in any of the cases after the first week. LEVEL OF EVIDENCE: Level III, case-control study.

Effects of Tibial Rotational-guided Growth on the Geometries of Tibial Plateaus and Menisci in Rabbits.

BACKGROUND: There are studies on the use of oblique plate over epiphyses for rotational deformities but the effects of this method on bone are not yet known. The purpose of this study was to determine the effect and rebound effect of rotational-guided growth on the geometries of the tibial plateaus and menisci in a rabbit model of tibial axial rotation. METHODS: Thirty male rabbits were 6 weeks old when medial and lateral plates were applied to the proximal tibias of the left side. After 4 weeks, 15 rabbits were euthanized (group 1), and the plates from the tibias of the remaining 15 rabbits (group 2) were removed. The rabbits in group 2 were euthanized 4 weeks later. RESULTS: In the rabbits of group 1, the most striking differences were a decrease in the lateral tibial slope (from 28.3 to 10.8 degrees) and decrease in the ratio of the lateral plateau covered by the meniscus (from 71.9% to 61.3%). After removing the plates (group 2), the observed values of the rebound effects were 25.9 and 29.8 degrees for the lateral tibial slope, and 76.5% and 77.2% for the ratio of the lateral plateau covered by the meniscus. However, the meniscal geometries continued to change. CONCLUSIONS: The rotational-guided growth provided by using plates caused a change in the tibial plateau geometry, and the rebound effect, except in the meniscal geometry, was observed after removing the plates in the growing period of the rabbits. Rotational-guided growth for the restoration of tibial axial rotation deformities may be suggested after determining the clinical effects of the increasing meniscal variables. LEVEL OF EVIDENCE: Clinical relevance: the rotational-guided growth needs close follow-up because of possible changes in anatomy of the bone.

Rotational deformities of the long bones can be corrected with rotationally guided growth during the growth phase.

Background and purpose - Coronal and sagittal plane long bone deformities can be corrected with guided growth, whereas transverse plane rotational deformities require osteotomy and internal or external fixation. We investigated whether rotational changes can be introduced with the plating technique. Methods - 45 rabbits (6 weeks old) were divided into 3 groups. The unoperated right tibia was used as control. In groups 1 and 3, two plates were placed obliquely to the long axis and in different directions. In group 2, a sham operation was performed with screws. Animals in groups 1 and 2 were followed for 4 weeks. In group 3 the implants were removed 4 weeks after the operation to observe rebound effect, and the animals were followed for another 4 weeks. The tibial torsion was assessed on computed tomography (CT). External rotation was accepted as a negative value. Results - In group 1, mean torsion was -20° (SD 7.9) in the right tibia and -2.9° (SD 7.2) in the left tibia (p < 0.001). In group 2, mean torsion was -23° (SD 4.9) in the right tibia and -26° (SD 6.5) in the left tibia (p = 0.2). In group 3, mean torsion was -21° (SD 6.3) in the right tibia and -9.5° (SD 5.3) in the left tibia (p < 0.001). Intergroup evaluation for left torsion showed a significant difference between group 2 and the other groups (p < 0.001). When the rebound effect was evaluated, there was no statistically significant difference between groups 1 and 3 (p = 0.08). Interpretation - A rotational change was attained with this technique. Although a rebound effect was seen after implant removal, it did not reach statistical significance. The final rotational change remained constant.

Increased turn/amplitude parameters following subvastus approach in total knee arthroplasty.

PURPOSE: To compare the improvement of the vastus medialis component of the quadriceps muscle electrophysiologically after the subvastus and medial parapatellar approaches in total knee arthroplasty (TKA). METHODS: A total 26 patients that underwent primary unilateral in TKA were included into the study. TKAs were carried out via subvastus approach in 15 patients, while 11 patients were operated via medial parapatellar approach. The electrophysiological evaluations were carried out blindly with regard to the type of the surgical approach before the operation and at 6th week post-operatively. Non-surgical side was also evaluated as a control. Assessments were patellar tendon reflex analysis, motor unit potential analysis and interference pattern analysis (IPA) including turn-amplitude analysis and IPA during maximum contraction. RESULTS: When they were compared to the pre-operative values, "the total mean amplitude" and "the mean turn/sec" parameters were significantly increased in group of subvastus approach (p = 0.017 and p = 0.009, respectively) at the post-operative 6th week. We would not be able to find any difference regarding the other electrophysiological parameters. There was also no significant difference between groups. CONCLUSION: If there was no significant difference in all the electrophysiological parameters, the increase in turn-amplitude analysis in the group of subvastus approach would be considered as an indicator of a faster functional improvement of knee extensor mechanism in these cases.

Tibial slope changes following guided growth by the eight-plate: A retrospective comparative study.

OBJECTIVE: The aims of this study were (1) to investigate the tibial slope (TS) changes following guided growth by the eight-plate and to determine the relationship between the TS change in the sagittal plane and the plate position. METHODS: In this retrospective study, children who underwent guided growth by the eight-plate for genu varum or valgum were included. Thirty-eight extremities of 23 children (14 girls and 9 boys; mean age = 9.2 years, age range = 3-17 years) were then divided into two groups according to the plate location in the sagittal plane (anterior or midline). Preoperative and postoperative TS were measured from the medial and lateral tibial plateaus separately. RESULTS: The mean follow-up was 34.3 (range = 12-96) months. The mean preoperative and postoperative medial TS were 4.05 ± 5.65 and 0.83 ± 3.91 degrees, respectively, in 18 patients in whom anterior epiphyseal plates were placed (P = 0.004). The mean preoperative and postoperative lateral TS were 4.88 ± 5.33 and 0.11 ± 3.34 degrees, respectively, in 18 patients in whom anterior epiphyseal plates were placed (P < 0.001). The mean preoperative and postoperative medial TS were 4.2 ± 5.19 and 4.9 ± 6.02 degrees, respectively, in 20 patients in whom midline epiphyseal plates were placed (P = 0.532). The mean preoperative and postoperative lateral TS were 5 ± 5.51 and 4.8 ± 5.7 degrees, respectively, in 20 patients in whom midline epiphyseal plates were placed (P = 0.871). Postoperative TS was decreased in anteriorly located eight-plates, and medial and lateral plateau measurement was significant (P = 0.004 and P < 0.001, respectively). Postoperative TS changes in midline-placed eight-plates were not significant regarding the medial and lateral plateaus (P = 0.532 and P = 0.871, respectively). CONCLUSION: The results of this study have shown that TS decreases following guided growth by the eight-plate in children in whom plates are placed at the anterior epiphysis. To prevent TS changes, the eight-plate should be placed in the midline position at the sagittal plane. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Are there any differences between the shoulder-arm sling and figure-of-eight bandage in the conservative treatment of paediatric clavicle fractures?

PURPOSE: Clavicle fractures are treated conservatively in the paediatric age group, except in rare types of fractures. We investigated whether there was a difference between using shoulder-arm sling and figure-of-eight bandage in this age group. METHODS: This study was designed as a retrospective study. In all, 41 children among 53 who underwent conservative treatment with a shoulder-arm sling or figure-of-eight bandage between 2014 and 2019 were included in the study and divided into two groups. Treatment results were compared clinically with respect to pain intensity, muscle strength and radiological examinations. RESULTS: Group A comprised 20 children with a figure-of-eight bandage and group B comprised 21 children with shoulder sling. According to the Robinson classification, ten fractures were displaced in group A and 12 in group B (p = 0.647). The mean time until the first appointment after the index visit that started the management course was 25.5 days (21 to 31) in group A and 24 days (20 to 30) in group B (p = 0.129). Fracture healing was observed in all patients at the first follow-up and the treatment was discontinued. There was no difference between the groups in the muscle strength examination and shoulder joint range of movement examination at the first-year follow-up (p = 1.00). CONCLUSION: In the paediatric age group, there was no significant difference between shoulder-arm sling and figure-of-eight bandage in the conservative treatment of clavicle fractures. Since the shoulder-arm sling is more suitable for treatment, it may be the primary preference. LEVEL OF EVIDENCE: Level III (retrospective comparative study).

The effect of hip reconstruction on gross motor function levels in children with cerebral palsy.

OBJECTIVE: The aim of this study was to determine whether the hip reconstruction has an effect on gross motor function classification system (GMFCS) levels in patients with hip instability in cerebral palsy (CP). METHODS: A total of 45 hips of 30 patients (mean age: 8.7 (4-17) years) with CP operated due to hip instability with a minimum of 2 years of follow-up were included into the study. Migration index was used for classification of the severity of hip instability. Clinical evaluation included sitting and walking ability, existence of pressure sores, difficulty in perineal care, and hip pain. The functional gains from the surgery were evaluated with changes in GMFCS levels. Wilcoxon T test, chi-square test and Spearman correlation test were used. RESULTS: Mean follow-up time was 57 (24-132) months. The distribution of preoperative GMFCS was level I in 1 patient, level II in 4 patients, level III in 5 patients, level IV in 9 patients and level V in 11 patients. The complaints resolved in 25 patients, and persisted in 5 postoperatively. There was no correlation between the changes in GMFCS levels and the postoperative complaints (p = 0.504). The GMFCS levels did not change in 20 patients, improved in 8, and worsened in 2. There were no significant differences between the preoperative and postoperative GMFCS levels (p = 0.052). Positive correlations were found between the preoperative GMFCS-MI, the type of CP-MI respectively (p = 0.001, p = 0.015). CONCLUSION: There was an improvement in preoperative complaints. GMFCS levels remained stable after surgery. Relief in symptoms was not consistent with the changes in GMFCS in children with cerebral palsy after hip reconstruction. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

[The microfracture technique in the treatment of full-thickness chondral lesions of the knee]. / Diz ekleminde tam kat kikirdak lezyonlarinin tedavisinde mikrokirik yöntemi.

OBJECTIVES: Chondral lesions of the knee joint present a difficult challenge because of their poor potential for spontaneous healing. In this study, we evaluated the results of the microfracture technique in the treatment of full-thickness chondral lesions. METHODS: The study included 20 patients (12 males, 8 females; mean age 44 years; range 18 to 60 years) who were treated with the microfracture technique for 22 lesions of osteoarthritis or traumatic chondral injuries. The patients were evaluated at the end of a mean follow-up period of 3.8 years with a visual analog scale and Lysholm II scores. Wilcoxon signed-rank test was used for statistical analysis. RESULTS: The size of the chondral lesions varied between 0.5 to 2.25 cm2. Most of the lesions were in the medial femoral condyle (n=11), followed by the medial femoral condyle and trochlear groove (n=4), the lower aspect of the patella (n=3), trochlear groove (n=3), and the lateral femoral condyle (n=1). The mean visual analog scale score was 69.5 (range 20 to 100) preoperatively and 11 (range 0 to 60) postoperatively (p<0.001). The mean Lysholm II score increased from a preoperative 73.7 (range 49 to 90) to a postoperative 86.1 (range 51 to 100) (p=0.017). CONCLUSION: The microfracture technique is a method that relieves the symptoms, and results in considerable improvement in the function and activity of the patients with full-thickness chondral lesions. The advantages of this arthroscopic treatment method are cost-effectiveness and low morbidity rate.

Incomplete Currarino triad as an embryological variant. Case report and review of the literature.

Currarino triad is a rare embryological complex of congenital caudal anomalies, including anorectal malformation, sacral osseous defect, and presacral mass, that results from abnormal separation of the neuroectoderm from the endoderm. The authors present an unusual case of a patient who had, in addition to the classic features of this syndrome, holocord syringomyelia, low conus medullaris, and tethered cord demonstrated by magnetic resonance imaging. They also discuss the embryological significance of this clinical entity and briefly review the relevant literature.

Preoperative magnetic resonance imaging evaluation of semitendinosus tendon in anterior cruciate ligament reconstruction: Does this have an effect on graft choice?

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction with ST autograft is sometimes unsuccessful because of harvested thin graft. Magnetic resonance imaging (MRI) can be a useful tool to evaluate the thickness of the graft. This study is performed to evaluate whether there is any correlation between diameters and cross-sectional area (CSA) of the semitendinosus tendon (ST) on the preoperative magnetic MRI and the diameter of the 4-stranded ST autograft in ACL reconstruction. MATERIALS AND METHODS: Seventy patients who underwent single-bundle ACL reconstruction with 4-stranded ST for full-thickness ACL ruptures were included in this study. Anteroposterior (AP) and mediolateral (ML) diameters of ST at the levels of the joint line (JL) and femoral physeal line (PL), and also CSA at these levels were measured on T2-weighted fat-suppressed MRI examinations. The data obtained were compared with intraoperatively measured diameters of 4-stranded ST autograft. Correlations between variables were evaluated using Spearman's rho. Receiver operating characteristic and area under the curve statistics were used to evaluate the cut-off value for the correlation between 4-stranded ST graft diameter of 8 mm and CSA (mm2) on MRI. RESULTS: On MRI measurements, no correlation was found between AP diameters at the level of the JL and 4-stranded ST diameter (P = 0.180). However, correlations were found between diameter of 4-stranded ST and ML diameter at the level of JL (P = 0.003) and PL (P = 0.002), AP diameter at the level of the PL (P = 0.009), CSA at the level of the JL (P < 0.001) and at the level of PL (P < 0.001). Correlation between the diameter of 4-stranded ST and CSA at both levels was more significant than that between AP-ML diameters of ST and diameter of autograft. The cut-off value for the 8 mm diameter CSA of 4-stranded ST was 5.9 mm2 at the JL and 8.99 mm2 at the PL. CONCLUSION: Preoperative MRI evaluation of CSA at the JL of the ST is a reliable parameter to predict graft size. Other graft alternatives should better be considered if the CSA of ST is <5.9 mm2 at the level of the JL.

A comparison of the effect of doxorubicin and phenol on the skeletal muscle. May doxorubicin be a new alternative treatment agent for spasticity?

Since spasticity is still an unsolved problem for orthopaedic surgeons, different chemical agents are tried before surgery. Phenol is a chemical agent which has been used for spasticity treatment for a long time. Doxorubicin is an antitumoral agent that has recently been used for chemomyectomy. The intramuscular effects of phenol and two different dose of doxorubicin were compared in that experimental study. In the first group 0.5 mg/0.5 cm3 doxorubicin, in the second group 1 mg/0.5 doxorubicin and in the third group 5% aqueous solution of fenol/0.5 injection were applied into left quadriceps muscle of rats. Degeneration areas were wider in the high dose doxorubicin group (29.9%; 8.5-61), in comparison with the low dose doxorubicin group (6.4%; 3.1-12) and phenol group (4%; 0-14) after 6 weeks. Differences in degeneration area among three groups were statistically significant (P<0.001). The difference was significant between the high dose doxorubicin group and the phenol group (P=0.001) and also between the high dose doxorubicin group and the low dose doxorubicin group (P<0.001). The results of this study suggested that doxorubicin could provide an alternative treatment modality for neuromuscular disease causing spasticity and it has a dose-dependent effect. Further studies are needed for long-term comparison and clinical use of doxorubicin for spasticity treatment.

A new guide for condylar blade-plate on distal femoral fractures.

This article presents a new guide used to reduce the risk of malalignment following distal femoral fracture fixation with a 95 degrees angled blade plate.

[In situ pinning on slipped femoral capital epiphysis with a single cannulated screw]. / Femur basi epifiz kaymasinda oldugu pozisyonda tek vida ile tespit.

BACKGROUND: Slipped femoral capital epiphysis requires immediate surgical intervention. Because this condition is relatively rare, the diagnosis is frequently delayed in patients with complaints of knee and hip pain and limping. Middle term results of patients who were diagnosed early and treated with a single cannulated screw are evaluated. MATERIAL AND METHOD: Five hips of 4 patients (3 male, 1 female) with slipped femoral capital epiphysis treated with a single cannulated screw between the years of 2000-2003 were evaluated under the light of literature findings. RESULTS: Mean patient age was 13 (range 12-14) years; mean slip angle was 33.2 degrees (range 26 degrees -40 degrees ); mean body mass index was 27.3 kg/m2 (range 25.6-29.8 kg/m2 ). After immediate immobilization, internal fixation with a single screw was applied without any reduction. CONCLUSION: During the mean follow-up period of 24 months (range 12- 41) epiphysial slipping progression was not observed and new epiphysial slipping did not develop on the contralateral hips. We are of the opinion that intervention for slipped femoral capital epiphysis with a single cannulated screw is a beneficial treatment. Although the number of our cases is limited we believe a close follow-up of the hip without prophylactic pinning should be the preferable alternative.

Ipsilateral supracondylar humerus fracture and Monteggia lesion with a 5-year follow-up: a rare injury in a young girl.

Although elbow injuries and fractures of the forearm are common in children, the combination of these injuries is rare. We present a case of a 5-year-old patient with a concomitant ipsilateral supracondylar humerus fracture and Monteggia lesion. After physical and radiographic examination of the injured extremity in the emergency department, closed reduction and percutaneous pinning were performed under image intensifier under general anaesthesia. A long-arm cast was applied for postoperative immobilisation. Excellent radiological and functional outcomes were obtained at the end of 1-year follow-up and no deformity was observed at 5-year follow-up.

Bone cement treatment for aneurysmal bone cyst in a dog.

An eighteen month old female Doberman pinscher dog was referred to teaching hospital of Adnan Menderes University, Faculty of Veterinary Medicine with the complaint of right forelimb lameness for a month. On the basis of clinical, radiographical, scintigraphical, computed tomographical and histopathological findings, aneurysmal bone cyst was diagnosed. Surgical curettage and bone cement treatment were applied. The patient recovered after 12 months. This case proves that aneurysmal bone cyst, without osteolysis and/or damages to the surrounding tissues, may result in a good prognosis if curettage and treatment with bone cement are done.

Brucellar spine infection--four case reports.

Brucellosis can be difficult to diagnose because of the nonspecific and variable clinical picture. This systemic disease is still an important public health problem in the Mediterranean Basin. These four cases of brucellar spine infection originated from rural areas around Aydin, Turkey. The systemic complaints of fever, profuse sweating, malaise, polyarthromyalgia, and weight loss indicated the final diagnosis of brucellosis and presumptive diagnoses were made based on agglutination testing for brucellosis. Computed tomography and magnetic resonance imaging indicated signs of bone infection and soft tissue involvement. Good outcomes were obtained with prolonged treatment with antibrucellar drugs including streptomycin, rifampicin, and tetracycline. Early diagnosis is important and prompt antibrucellar chemotherapy is effective in most cases, but prolonged follow up is necessary in all patients with spinal brucellosis.

[Stress fractures in children and adolescents]. / Cocukluk ve ergenlik döneminde olusan yorgunluk kiriklari.

The incidence of stress fractures in young athletes has increased with the popularization of sports among children and adolescents. Stress fractures are less common in children and adolescents than in adults. A combination of intrinsic or anatomical factors and extrinsic factors such as training pitfalls and environmental insufficiencies predispose athletes to stress fractures. This review aims to outline current knowledge about clinical manifestations, diagnostic imaging, and treatment of stress fractures in children and adolescents.

[Doxorubicin-induced chemomyectomy effects in rat skeletal muscle]. / Doksorubisinin siçan iskelet kasinda kemomiyektomi etkisi.

OBJECTIVES: This study was based on the assumption that decreased number of active muscle fibres in the spastic muscle may be associated with restoration of the balance. Hence, the effect of doxorubicin was evaluated in inducing permanent cell necrosis on skeletal muscle (chemomyectomy). METHODS: Eighteen Wistar rats were divided into two groups, equal in size, to receive doxorubicin injections (0.02 and 0.05 mg/0.5 ml) into the left quadriceps muscles under general anaesthesia. The right quadriceps muscles (controls) were assigned to receive 0.5 ml of physiologic saline solution. Three rats in each group were sacrificed on the 1st, 6th, and 10th post-injection weeks, after which all the quadriceps muscles were histologically evaluated. RESULTS: Histopathologic findings were normal in the control muscles. Dose-dependent acute inflammatory reactions were observed in both groups at the end of the first week, with a higher severity at 0.05 mg doses. The size of the inflammation areas were 2.5% and 10% at 0.02 mg and 0.05 mg doses, respectively. At the end of six weeks, acute inflammatory reactions were replaced by the development of regeneration and fibrosis accounting to 0.8% of all the areas, regardless of the dose given. Specimens of the 10th week exhibited no regeneration; there was a mean of 2.5% fragmentation within the impaired areas, with atrophic fibrils and marked fibrosis showing no dose-dependence. CONCLUSION: Doxorubicin induces a dose-dependent inflammatory reaction during the early postoperative period. In the long-term, permanent effects, which are not dose-dependent, are observed characterized by fragmentation, atrophy, fibrosis of muscle fibres, and losses in contractile muscle elements. These doxorubicin-induced chemomyectomy effects may prove therapeutic in the treatment of spasticity-associated diseases.

[How effective is in situ pinning with single screw fixation in mildly or moderately slipped capital femoral epiphysis?]. / Femur basi epifizinin hafif veya orta siddetli kaymasinda tek vida ile oldugu pozisyonda tespit ne kadar etkilidir?

OBJECTIVES: This study aims to evaluate the outcomes of mild and moderate slipped capital femoral epiphysis (SCFE) treated with in situ pinning. PATIENTS AND METHODS: Eighteen hips of 15 patients (11 boys, 4 girls; mean age 12 years; range 9 to 15 years) with chronic stable SCFE were treated with in situ pinning. Immediate immobilization and internal fixation were applied. The results were evaluated according to Heyman Herndon's clinical and Boyer's radiologic classification system. RESULTS: The mean follow-up was 56 months. The mean slipping angle was 38°, while the mean body mass index was 26 kg/m2. The mean preoperative hip flexion, internal and external rotation were respectively 94°, 9°, 59° and the mean postoperative hip flexion, internal and external rotation were 120°, 28°, 56°, respectively. The results were completely successful according to the Heyman Herndon's clinical and Boyer's radiologic classification system. The Trendelenburg test was negative in all patients. There was an asymptomatic CAM-type femoroacetabular impingement in one case, while history of femoral shaft fracture treated with surgically in the SCFE side and limb length discrepancy in one case. CONCLUSION: In this study, we obtained successful clinical and radiological results of fixation with in situ pinning in patients with chronic stable mildly or moderately slipped capital femoral epiphysis without reduction. There were no clinical signs related to arthrosis and impingement syndrome in mid-term follow-up.