Management preferences of orthopedic surgeons in developmental dysplasia of the hip under 1 year of age in Türkiye: Results of a nationwide cross-sectional survey.

OBJECTIVE: This study aimed to evaluate the diagnosis and treatment preferences of orthopedic surgeons in developmental dysplasia of the hip (DDH) cases under the age of 1 in Türkiye with a higher incidence of DDH, estimated to be around 5-15 per 1000 live births. METHODS: This was a nationwide cross-sectional survey. A link for the online survey, including 16 multiple-choice questions, was sent to the email group of the National Orthopedic Society. RESULTS: Among 233 filled-out surveys, 211 met the inclusion criteria. Half of the participants had experience of <10 years as orthopedic surgeons, managed <25% of pediatric patients in daily practice, and treated <25 DDH cases per year before walking age. Ninety-seven percent used more than one method, hip ultrasound the most common, for exact diagnosis of DDH under 6 months. Pavlik harness was the most commonly preferred brace, but the use of Tübingen orthosis increased among experienced surgeons. The uppermost age limit for bracing was higher in surgeons dealing with more pediatric patients and treating more DDH cases. Dislocated hips and hips requiring closed/open reduction were more commonly referred to other surgeons by less experienced surgeons in terms of years, number of pediatric patients, and treated DDH cases per year. The lowest age limit for intervention under general anesthesia was lower in surgeons treating >25 DDH cases per year. Over one-third used both anterior and medial approach open reduction, but a trend to anterior open reduction alone was more evident in surgeons treating >50 DDH cases per year. More experienced surgeons were more prone to check the intraoperative reduction with postoperative computed tomography or magnetic resonance imaging. Diagnosis and treatment ages of DDH cases did not significantly change during the coronavirus disease 2019 pandemic. CONCLUSION: Management preferences of orthopedic surgeons in DDH before walking age primarily depend on the rate of pediatric patients in daily practice and the number of treated DDH cases per year.

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.

Prevalence, Incidence, and Surgical Treatment Trends of Cerebral Palsy across Türkiye: A Nationwide Cohort Study.

BACKGROUND: Cerebral Palsy (CP) is the most prevalent neurodevelopmental disorder in childhood. Our aim is to identify the demographics of CP in Turkish children in addition to clinical associations and surgical preferences. METHODS: Based on national health system data and the International Classification of Diseases (ICD)-10 code for CP, data were evaluated from a total of 53,027 children with CP born between 2016 and 2022, and 9658 of them underwent orthopedic surgery in those years. The incidence and frequency of CP were assessed for the parameters of age and gender. Age at the time of surgery; codes pertaining to surgical interventions; and regions, cities, and hospitals where diagnoses and surgical procedures were performed were also evaluated. RESULTS: There were 29,606 male (55.8%) and 23,421 (44.2%) female patients. The diagnoses of the patients were mostly (76.1%) performed in secondary and tertiary hospitals. The prevalence of CP among children in 2016-2022 was estimated to be 7.74/1000 children. The minimum and maximum incidence rates of cerebral palsy among children between 2016 and 2022 were calculated to be 0.45 and 1.05 per 1000, respectively. Tenoplasty-myoplasty tendon transfer operations were the most common surgeries (47.1%). CONCLUSION: CP remains a significant health challenge, underpinning a considerable proportion of childhood motor dysfunction. A dedicated national registry system for CP focused on classifying the condition, streamlining treatment, and tracking outcomes would be a valuable tool in our collective efforts to address this critical issue more effectively.

Efficacy of balance training on postural control in patients with rotator cuff disease: a randomized controlled study.

We evaluated the efficacy of adding balance training to a physical therapy program on postural control and health-related quality of life in patients with rotator cuff disease. Forty-two participants were randomly allocated to the control and intervention groups. Both groups received physical therapy (education, stretching, supervised strength training, and home exercise program) 3 days/week for 6 weeks. The intervention group was instructed to perform balance exercises at home. The primary outcomes were the stability index, the Fourier transformation (F5 and F6), the weight distribution index, and the fall index, as assessed by the posturography during eight conditions with different combinations of standing (solid surface, pillows, and different head positions) and vision (eyes open/closed). The secondary outcomes included the Western Ontario Rotator Cuff Index to assess the health-related quality of life, the Shoulder Pain and Disability Index, and the Numeric Pain Rating Scale. The adherence to in-person and home-based therapy was high (>83%). The intervention group significantly improved the stability index, F5, and F6 parameters but each in only one condition (P < 0.05). No significant improvement was found in the conditions for the other primary outcomes and in the health-related quality of life. (P > 0.05). We conclude that adding the balance training protocol to the physical therapy program does not improve postural control and health-related quality of life in patients with rotator cuff disease.

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.

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.

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.

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.

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.

Preoperative planning of femoral head reduction osteotomy using 3D printing model: A report of two cases.

The deformed and enlarged femoral head secondary to hip diseases such as Legg Calve Perthes and Developmental Dysplasia usually causes impingement between the aspherical head and the acetabulum. To restore and reduce the size of enlarged femoral head, a femoral head reduction technique has been described previously. The goal is to obtain a spherical femoral head and to cover the gliding surface with best available cartilage. Planning of osteotomy to achieve spherical head is the crucial point of surgery. It is usually done intra-operatively and dependent on experience of surgeon. Preoperative 3- Dimension (D) modeling of femoral head is commonly preferred to minimize this risk. In this technical note, preoperative planning with 3-D printing was demonstrated in two separate patients with Legg-Calve-Perthes Disease and developmental hip dysplasia. Surgical time was approximately 150 and 120 min, respectively. Blood loss was 230 and 300 cc, respectively. Patients were followed up 9 months and 12 months, respectively. None of the patients in this study developed avascular necrosis; however, the follow-up period is very limited. Moreover, none of the patients developed post-operative complications or required additional surgery. With a more detailed preoperative planning done on computer model and printed in 3-D, one can mimic the surgical procedure before the procedure. Finally, this technique is advantageous both for the patient and surgeon.

Intra- and inter-observer reliability of Laredo classification system in Legg-Calvé-Perthes Disease.

The purpose of the current study was to investigate intra- and inter-observer reliability of arthrographic Laredo classification system in Perthes disease. Forty-seven patients were included in this cross-sectional descriptive study. Patients' age, gender, physical findings and hip arthrographs were collected from hospital medical records. Two different sets of power point slides were prepared in which the order of cases was randomized and blinded. Observers were divided into three groups according to their surgical experience (9 residents, 10 seniors, 10 pediatric orthopedists), and they assessed two times 1 month's intervals. Statistical analysis was performed by using the SPSS v21. Inter- and intra-observer reliabilities were calculated using intra-class correlation coefficient, weighted kappa and percentage agreement. Percentage agreement of Laredo classification was about 50% for all groups (residents, seniors and pediatric orthopedists); intra-observer reliabilities were excellent, excellent and fair, respectively. Inter-observer reliability of Laredo classification for each set was found to be excellent for all groups. Length of experience did not correlated significantly with the level of intra-observer agreement. As a conclusion, our results showed that Laredo's arthrographic classification system's intra-observer reliability is at least at a fair level and inter-observer reliability is at an excellent level. We believe that this classification system is valuable for an orthopedic surgeon who deals with the treatment of Perthes disease.

Management of early-onset hip osteoarthritis in an adolescent patient with osteopetrosis tarda: a case report.

Osteopetrosis (OP) is a group of rare sclerosing bone dysplasia characterized by increased bone density. The benign autosomal dominant form is the most common type. It typically carries a full life expectancy, despite increased propensity for fractures and other musculoskeletal problems, particularly hip osteoarthritis. In the current literature, the youngest OP patient having hip osteoarthritis is 16 years of age and treated with total hip arthroplasty. Within the present study, a 16-year-old female patient with early-onset hip osteoarthritis treated with hip joint debridement and femoral head reshaping is presented. The pain relieved and hip joint movements recovered to almost normal range. At the final follow-up at 2 years after the surgery, the patient was still free of pain and ambulating without restriction. Hip joint debridement and femoral shaping may be beneficial in hip osteoarthritis secondary to OP in adolescents, and may delay hip arthroplasty in a young age.

Conservative Follow-up of Severely Displaced Distal Radial Metaphyseal Fractures in Children.

Introduction Distal radius fractures are the most frequent fractures seen in pediatric population and usually treated with closed reduction and casting. However, there is a risk of reduction loss and/or angulations in distal radial metaphyseal fractures. The purpose of this study is to evaluate the radiological and functional results of pediatric patients with distal radius metaphyseal fractures in which excessive displacement and/or angulations were accepted and to question upper acceptable limits in light of current literature. Methods Patients between five and 15 years of age with displaced distal radius fractures who were treated conservatively with significant angulation or translation were included in this study. Patients' demographic data were gathered from hospital's digital database. Clinical and radiological evaluations of all patients were done prospectively based on the last outpatient clinic control. Range of motion of wrist and elbow joint was measured with a goniometry, neurovascular status was documented, muscle strength was assessed and finally existing deformity measurements were performed clinically. Radiological evaluation was performed on pre-reduction, post-reduction, cast removal, 6th and 12th months and final examination radiographs. All measured values were compared with uninjured side. Radiologically, the percentage of translation, the amount of angulations, the distance from the fracture to the epiphyseal line, and the radius lengths were measured. Radial inclination and palmar tilt angles as well as ulnar variance and residual angulation were measured in both antero-posterior (AP) and lateral forearm radiographs. The Mann-Whitney U test was used to compare the variables in SPSS version 21. p < 0.05 was considered statistically significant. Results Twenty-nine patients with a mean age of 8.8 ± 3.1 years were included in this study. The mean follow-up duration was 17.4 ± 6.7 months. Compared to the uninjured side, in 24 (83%) patients, there were no limitations on wrist movements except five patients in forearm pronation clinically. In patients with re-displacement, the mean displacement occurrence time was 13.3 ± 4.9 (7-21) days. The translational and/or angulations in AP and lateral radiographs fully remodeled at the end of 6th month. Conclusion This study demonstrates that radial and dorsal angular deformities up to 39° and 22° volar angulation and complete displacement correct fully in children up to 10 years old. In children between 10 and 15 years, the dorsal angulation up to 38°, radial angulation up to 23°, and volar angulation up to 16° are acceptable for remodeling capacity of the child.

Analysis of the factors causing tight cast syndrome after closed reduction and casting of pediatric distal radius fractures.

OBJECTIVE: The aim of this study was to evaluate the most important factors which can cause "tight cast syndrome'' (TCS) in pediatric patients with distal radius fractures. METHODS: Patients, who were at or under 15 years old and treated conservatively with an diagnosis of distal radius fracture between August 2015 and August 2017 were included in to the study. Fifty four patients, who had been found to experience TCS were accepted as group 1 and sixty-two patients without TCS as group 2. Cast index, pre-/post reduction translation, pre-/post reduction angulation, localization and displacement of the fracture, need for re-manipulation, and presence of associated distal ulna fracture were evaluated for both groups. Statistical analysis was performed to evaluate cut off value for cast index values for both TCS and loss of reduction and logistic regression analysis of the other possible factors. RESULTS: Pre-/post-reduction translation (over 50% and 10%, respectively) (odds ratios:0.167 and 0.524, respectively), a cast index value below than 0.775 (odds ratio:3.080), displaced type fracture (odds ratio:8.028), presence of re-manipulation (odds ratio:0.131) and associated distal ulna fracture (odds ratio:2.029) were found to be statistically significantly important for the occurrence of TCS. The most important factors were decreased cast index value and presence of initially displaced type fracture. Loss of reduction (LOR) risk was found to be increased in patients with a cast index value of greater than 0.875. CONCLUSION: One should be very careful when following a pediatric patient who have a displaced distal radius fracture which has initial/post reduction translation in AP plane, which is associated with distal ulna fracture, which required re-manipulation and most importantly which cast index is under than 0.775 in terms of occurrence of TCS. We recommend obtaining a cast index value between 0.775 and 0.875 to prevent both TCS and LOR. LEVEL OF EVIDENCE: Level III, Therapeutic study.