Radiographic Impact on the Clinical Decision Making of Achilles Tenotomy in Clubfoot: In Search of an Objective Cut-Off Value.

BACKGROUND: We tried to determine whether the indication of Achilles tenotomy (AT) in clubfoot patients based on clinical evaluation could be confirmed radiographically, and to find an objective radiographic cut-off value for its indication. METHODS: Eighty-six clubfeet from 60 patients, (26 bilateral and 34 unilateral) were included. A standard Ponseti treatment regimen was applied. Group 1 comprised patients who underwent AT immediately after serial plaster casting (26 feet). Group 2 comprised patients who underwent AT during the follow-up period (48 feet). Group 3 comprised patients who were assumed to have a corrected foot and did not undergo AT (12 feet). Group 4 comprised the healthy sides of the unilateral cases (34 feet). RESULTS: Both Group 1 and Group 2 showed significant improvement after tenotomy (p = 0.002). In order to differentiate between the normal and AT groups according to the pre-tenotomy angle, we obtained an optimal cut-off value of >85° according to the Youden index, a sensitivity of 96%, a specificity of 91.2%, a positive predictive value of 95.9%, a negative predictive value of 91.2%, and an accuracy rate of 94.4% (AUC: 0.983; p < 0.001). CONCLUSIONS: Feet with a lateral tibio-calcaneal angle > 85° can be considered pathologic and accepted as candidates for AT.

Bosworth and modified Phemister techniques revisited. A comparison of intraarticular vs extraarticular fixation methods in the treatment of acute Rockwood type III acromioclavicular dislocations.

OBJECTIVE: The aim of this study was to compare the long-term clinical and radiological results of Acromioclavicular (AC) fixation with K-wires (the modified Phemister procedure) and Coracoclavicular (CC) fixation with the Bosworth screw in the surgical treatment of Type 3 AC joint dislocations. METHODS: Thirty-two patients with complete set of medical records and who received surgical treatment between September 2005 and January 2009 due to acute Rockwood Type 3 AC joint dislocation and properly attended their follow-ups were retrospectively evaluated. Sixteen patients (13 males, 3 females; mean age: 38, range: 24-52 years) were treated with CC fixation with Bosworth screw (Group 1), and the other 16 (12 males, 4 females; mean age: 53.3, range: 38-64 years) with AC fixation using K-wires (Group 2). RESULTS: The mean follow-up time was 96 months for Group 1 and 93 months for Group 2 patients (p > 0.05). The mean Constant-Murley score at the final follow-up was 84.7 in Group 1 and 87.3 in Group 2 (p = 0.069). Radiological evaluation of the patients revealed AC arthrosis in 2 and 3 patients in Group 1 and 2, respectively. In Group 2, one patient had a recurrent dislocation, three patients had AC arthrosis and two patients had ossification in the CC ligament (Fig. 2). There was no superficial or deep wound infection in Group 1, while two patients from Group 2 had a superficial wound infection. CONCLUSIONS: Our results suggest that both techniques are reliable and provide adequate reduction and similar outcomes in terms of functionality and pain levels, following the reduction of Type 3 AC joint dislocations. With lower rates of wound site infection in the early and AC arthrosis in the late postoperative period, CC fixation method with the Bosworth screw may be a better surgical option than AC fixation method with K-wires. LEVEL OF EVIDENCE: Level III, Therapeutic study.

A comparison of continuous femoral nerve block and periarticular local infiltration analgesia in the management of early period pain developing after total knee arthroplasty.

OBJECTIVE: This study aimed to compare the effects of 24-h continuous femoral nerve block (CFNB) and periarticular infiltration analgesia (PIA) on postoperative pain and functional results in the first 6 weeks after total knee arthroplasty (TKA). METHODS: Sixty patients who underwent unilateral TKA were included in this study. The patients were divided into two groups: Group A received CFNB and Group B received PIA. Each patient received 0.25% levobupivacaine and 1:100,000 epinephrine as infiltration to the posterior capsule. A patient-controlled analgesia (PCA) device was used for all patients, and 24-h tramadol usage by patients was recorded. We measured maximum range of motion (ROM), pain using a visual analog scale (VAS), 2-min walk test (2MWT), and the scores of Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Knee Society Score (KSS). RESULTS: Compared with Group B, Group A had lower postoperative opioid usage (p<0.05), less pain at rest (p<0.05), less pain with passive motion (p<0.05), less pain with movement and after active movement (p<0.05), and superior passive and active ROM (p<0.05). Group A also had better 2MWT results at 24 and 48 h after surgery (p<0.05), and superior WOMAC and KSS results at 6 weeks after surgery. CONCLUSION: As long as it is applied with infiltration analgesia to the posterior capsule, CFNB is an effective and safe analgesia method resulting in better postoperative patient comfort and greater ROM. Furthermore, it produces better results in the early postoperative period with a favorable side effect profile.

Total knee arthroplasty for the management of joint destruction in tuberculous arthritis.

PURPOSE: The purpose of this study was to evaluate our experience to clarify the suggestion that there should be a significant disease-free interval before total knee arthroplasty (TKA) and to determine the correct timing of surgery for reconstruction of the joint destruction in patients suffering from tuberculous arthritis. METHODS: Twelve patients with advanced joint destruction and tuberculous arthritis of the knee with recent onset were reviewed in this study. The time interval from our diagnosis of active infection to arthroplasty averaged 4 ± 1.5 months. Histopathology of the biopsy specimens revealing granulomatous lesions, including epithelioid histiocytes surrounded by lymphocytes, confirmed the diagnosis of each patient. A primary knee prosthesis was performed in seven knees. In five knees, there was severe bone loss after the extensive debridement of the entire joint, and thereafter, revision prosthesis was preferred to preserve the joint line. Patients were given post-operative antituberculous treatment for a total of 1 year, whereas for three patients, whose erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values remained above normal by the sixth month, the chemotherapy was continued for up to 18 months. The Knee Society TKA roentgenographic evaluation and scoring system was used for radiological evaluation of the knees. Clinical evaluation of the knees was done preoperatively and at the time of the most recent follow-up using the American Knee Society Scoring System. RESULTS: Within the average follow-up period of 6.1 ± 1.8 years, no reactivation of tuberculous infection was found in any of the patients. ESR was normal, less than 20 mm/h, after a mean time of 5.5 ± 2.0 months. The CRP was normal, less than 0.8 mg/dl, after a mean time of 4.6 ± 1.3 months. At the most recent follow-up, the average knee score improved from 32.4 ± 19.4 to 83.4 ± 14.0 points (p < 0.05), and the average function score improved from 33.3 ± 11.9 to 86.6 ± 7.7 points (p < 0.05). Ten knees showed good integrity, and no radiolucent lines were found in the bone-prosthesis interface in relation to any component. Radiolucent lines were apparent on the tibial side in two knees. They were less than 1 mm thick and non-progressive, and clinically, there was no evidence of loosening of the component. Culture specimens were positive for five patients. CONCLUSIONS: TKA is a safe procedure for tuberculous arthritis with recent onset providing symptomatic relief, functional improvement and early return to activity when performed in correct time. A long disease-free interval should not be a prerequisite for arthroplasty. Wide surgical debridement is the mainstay to eradicate the disease, and post-operative antituberculous chemotherapy controls the residual foci. LEVEL OF EVIDENCE: IV.

Sciatic nerve compression by an extrapelvic cyst secondary to wear debris after a cementless total hip arthroplasty: A case report and literature review.

INTRODUCTION: Polyethylene (PE) wear debris after total hip arthroplasty (THA) may cause formation of a soft tissue mass due to inflammatory reaction. To the best of our knowledge we report the first case in whom the diagnosis was made after examination of the hip, pelvis and lumbar spine with detailed radiological methods and the plain radiographs showed no signs of loosening of the THA. PRESENTATION OF CASE: We report a 52 years-old woman who presented with a cyst causing sciatic irritation in her gluteal region due to wear debris after THA. Magnetic resonance imaging (MRI) was useful in detecting the cyst. Resolution of the cyst occured after subtotal cystectomy and revision of the acetabular components. DISCUSSION: Although plain radiographs can show signs of the underlying pathology; such as osteolysis, loosening of the components and wear of the PE liner, they are unable to detect cystic lesions. Cystic lesions may be an early sign of wear debris. CONCLUSION: This case shows us that sciatic neuropathy with no evidence of nerve root impingement on lumbar MRI in a patient with THA requires also examination of the hip and pelvis with detailed radiological methods, such as MRI, in addition to plain radiography. Removal of the source of debris via revision surgery following subtotal cystectomy leads to the resolution of the remaining portion of the cyst and also relief of the symptoms of sciatic nerve compression.

The results of closing wedge osteotomy with posterior instrumented fusion for the surgical treatment of congenital kyphosis.

PURPOSE: There exist not much data regarding the surgical treatment of pure congenital kyphosis (CK) in the literature. The purpose of this study was to evaluate the results of closing wedge osteotomy with posterior instrumented fusion in patients with congenital kyphotic deformity. METHODS: We retrospectively evaluated the radiographical results of 10 patients who were subject to closing wedge vertebral osteotomy and posterior instrumented fusion due to CK. The mean age of the patients at surgery was 12.6 ± 3.72 years (range 8-18 years). Radiographical measurements including local kyphosis, correction loss, global kyphosis and sagittal balance values were noted for the preoperative, postoperative and final follow up periods, respectively. The data obtained from those periods underwent statistical analysis. RESULTS: Average follow-up period was 51.8 ± 29.32 months (range 26-96 months). The mean local kyphosis angle was 67.7° ± 15.64° (range 42°-88°) prior to the surgery, 31.5° ± 17.12 (range 14°-73°) following the surgery and 31.9° ± 15.98° (range 14°-71°) during the follow up-period, respectively (p < 0.05). A correction rate of 53.5 % was reported at the final follow up. Average sagittal balance was measured as 33.1 ± 24.48 mm (range 2-77 mm) prior to the surgery, 20.8 ± 15.46 mm (range 5-46 mm) following the surgery (p < 0.05) and 14.1 ± 9.2 mm (range 0-30 mm) during follow-up period (p > 0.05). Complications consisted of a rod fracture due to pseudoarthrosis, an implant failure with loosening of screws and a proximal junctional kyphosis. No neurological deficit or deep infection were encountered in any of the patients in the study group. CONCLUSION: Closing wedge osteotomy with posterior instrumented fusion is an efficient method of surgical treatment in terms of sagittal balance restoration and deformity correction in patients with congenital kyphosis.

[Treatment of a pregnant patient with bilateral traumatic bimalleolar ankle fracture: a case report]. / Gebe hastada iki tarafli travmatik bimalleoler ayak bilegi kirigi tedavisi: Olgu sunumu.

The incidence of ankle fractures has been increasing among all fractures due to skeletal traumas. Bimalleolar fractures account for 25% of all ankle fractures. Bilateral traumatic bimalleolar ankle fracture is a very rare condition. In such a clinical presentation, pregnancy managed with cesarean procedure complicates the situation due to increased risk of venous thromboembolism and fatal pulmonary embolism. In this article, we report a 25-year-old female case within an eight-month pregnancy period who had bilateral bimalleolar ankle fracture due to an accident in a motor-vehicle and the clinical and radiological results of surgical treatment were discussed in the light of current literature data.

Clinical and radiological outcome of the growing rod technique in the management of scoliosis in young children.

OBJECTIVE: The aim of this study was to investigate the effects of growing rod treatment on the clinical and radiographic outcome and respiratory function of young children with scoliosis. METHODS: Data from 25 patients (24 females, 1 male) who underwent surgical treatment with growing rods for scoliosis between 1997 and 2007 were evaluated retrospectively. Dual growing rods were used in 16 patients and single growing rods in 9. Patients' average age was 7.38 ± 3.8 years at the initial surgery. Cobb angle, T1-S1 length, and instrumentation length were measured radiographically. Respiratory functions were evaluated at the final follow-up. RESULTS: Patients received an average of 4.2 lengthening treatments over an average period of 44.9 months. Cobb angles improved from 56.7° to 25.1° after final fusion. T1-S1 length increased from 27.2 ± 3.4 to 34.9 ± 3.6 cm after the initial surgery and 38.6 ± 3.7 cm post final fusion. Average growth was 1 ± 0.4 cm per year. Mean values of respiratory parameters at the last follow-up were FVC: 83.5 ± 3.5, FEV: 84.8 ± 5.3, and FVC/FEV1: 1 ± 0.046. Twelve patients experienced complications, of which eight were instrument-related and four medical. CONCLUSION: The growing rod technique is effective in the treatment of spinal deformity in young scoliosis patients and appropriate for improving both spinal column height and pulmonary function.

Effect of PEEK polymer on tunnel widening after hamstring ACL reconstruction.

The purpose of this study was to evaluate the effect of the AperFix device (Cayenne Medical, Inc, Scottsdale, Arizona), composed of polyetheretherketone (PEEK) polymer, on tunnel widening after hamstring anterior cruciate ligament (ACL) reconstruction as compared with 2 other fixation devices: the TransFix (Arthrex, Inc, Naples, Florida) and the EndoButton (Smith & Nephew Endoscopy, Mansfield, Massachusetts). Sixty-seven patients with isolated total ACL ruptures who underwent arthroscopically assisted reconstruction using hamstring autografts at the authors' institution were included in the study. Patients were assigned into 1 of 3 groups in a nonrandomized fashion: AperFix (n=18), TransFix (n=29), and EndoButton (n=20). Mean follow-up was 30 months. Tunnel widening measurements were performed on anteroposterior and lateral digital plain radiographs taken in postoperative week 1 and at final follow-up. Laxity testing, Lysholm scoring, and arthrometric evaluation were performed.All 3 graft fixation devices resulted in significant tunnel widening in both tibial and femoral tunnels at final follow-up when compared with the immediate postoperative period. Tunnel widening between groups was not significantly different in terms of coronal and sagittal femoral tunnel diameters. Tibial tunnel diameter increase in the sagittal plane in the EndoButton group was significantly smaller than that in the TransFix and AperFix groups. No correlation was found between the amount of tunnel enlargement and clinical outcomes of ACL surgery. This study's findings suggest that tunnel enlargement after ACL reconstruction is influenced by the type of graft fixation on the tibial side irrespective of clinical outcome, and PEEK polymer does not have an effect on tunnel widening after hamstring ACL reconstruction.

Evaluation of shoulder balance through growing rod intervention for early-onset scoliosis.

STUDY DESIGN: Retrospective clinical study. OBJECTIVE: To compare the single and dual growing rod techniques with an emphasis on shoulder balance in the surgical treatment of early-onset scoliosis. SUMMARY OF BACKGROUND DATA: In the literature, there exist not much data about shoulder balance through growing rod intervention using either single or dual rods for progressive scoliosis in patients of young age. METHODS: A total of 20 patients with early-onset scoliosis who were treated surgically using growing rod techniques (11 patients: single rod group, 9 patients: dual rod group) were analyzed radiographically. Radiographical measures of shoulder balance (difference of coracoid process height, clavicula-tilt angle, and clavicula-rib cage intersection point) and scoliosis of both groups that were obtained in the preoperative, postoperative, and final follow-up period underwent statistical analysis in comparison with each other. RESULTS: Both single and dual growing rod techniques improved the deformity correction, maintained the correction and allowed spinal growth in the surgical treatment of early-onset scoliosis. Single rod technique had a higher incidence of rod breakage. Both techniques effected the shoulder levels similarly. CONCLUSIONS: When evaluated separately, single rod technique does improve shoulder balance significantly. For a more definitive evaluation, a comparison study having more patients in both groups is essential.

The use of a cementless modular stem in the treatment of subtrochanteric femoral fractures in conjunction with ipsilateral coxarthrosis.

Subtrochanteric fractures of the femur below an arthritic hip are uncommon and challenging to orthopedic surgeons. Most of these fractures occur in elderly patients with advanced osteoporosis. The treatment choices consist of treatment of the fracture and the above hip joint versus treatment of the fracture alone. This study evaluates the clinical and radiological outcomes of arthroplasties performed to treat both conditions in a single surgery with the use of a cementless modular revision stem. Twelve subtrochanteric femoral fractures of 12 patients (9 women, 3 men) with a mean age of 76.4 years (range, 62-88 years) were treated with cementless modular revision stems. Total hip arthroplasty was performed with cementless femoral and acetabular component fixation. All hips received the same femoral and acetabular implants. All patients had comorbidities and the average American Society of Anesthesiologists score was 2.3 (range, 1-3). Ten of the 12 hips (83%) required an assistance device for ambulation before the trauma. There were 2 Dorr Type A (17%), 3 Dorr type B (25%), and 7 Dorr type C (58%) femora. The mean postoperative Harris Hip Score was 83 (range, 72-92) with a mean follow-up of 4.3 years (range, 2-7 years). At final follow-up, 9 hips (75%) were ambulatory without support (P=.016). Ten hips (83%) were able to both ambulate and walk up and down stairs. Two hips (17%) were able to ambulate but could not climb and descend stairs. Union was achieved in all femora at an average of 22.3 weeks (range, 16-32 weeks). Radiographic findings demonstrated stable ingrowth of the femoral prosthesis with no evidence of subsidence in 11 hips (92%). The average Engh score for all femora was 20.2 (range, 10-26). There was no relationship between the bone morphology (Dorr type) of the femoral medullary canal and the bone ingrowth scores of Engh (P=.639).

Results of 'two above- one below approach' with intermediate screws at the fracture site in the surgical treatment of thoracolumbar burst fractures.

The aim of this retrospective clinical study was to evaluate and compare the results of the technique so called 'two above one below approach' with intermediate screws at the fracture site with long-segment posterior fusion in the surgical treatment of thoracolumbar burst fractures. For this purpose neurologically intact 27 patients having isolated one level thoracolumbar burst fracture underwent posterior instrumentation and fusion in our clinic via 'two above-one below approach' with intermediate screws at the fracture site. A control group consisting of 15 patients having one level thoracolumbar burst fracture treated with long segment posterior spinal fusion in our institute was formed. At the preoperative, postoperative and final follow up period, anterior body height loss, local kyphosis and sagittal index values of both groups were noted. At the final follow up Visual Analogue Pain Scale and Oswestry disability scores were noted. Retrospective data from both groups underwent statistical analysis. In both groups anterior body height loss, local kyphosis and sagittal index measurements improved at the final follow-up, but there was no significance between two groups in terms of radiological and clinical follow-up data. The loss of correction in local kyphosis of short-segment group in the interval between postoperative and follow-up period was also significant. No implant failure was noted. As a conclusion 'two above one below approach' with intermediate screws at the fracture site is associated with loss of correction radiographically, but favorable clinical outcomes in the presence of any implant failure can be achieved in the treatment of thoracolumbar burst fractures.

AperFix versus transfix in reconstruction of anterior cruciate ligament.

The aim of this retrospective study was to compare clinical outcomes of the TransFix (Arthrex Inc., Naples, FL) fixation method and the brand-new AperFix (Cayenne Medical, Scottsdale, AZ) device in arthroscopic reconstruction of anterior cruciate ligament. A total of 38 patients with isolated complete anterior cruciate ligament rupture underwent arthroscopic reconstruction via two different fixation methods using hamstring autografts. Patients were evaluated in terms of range of motion values, Lysholm scores, laxity testing, and complications. Average flexion was 136.53 +/- 6.9 degrees in the TransFix group and 126.32 +/- 4.9 degrees in the AperFix group (p < 0.001). Mean Lysholm score was 82.42 +/- 8.5 in the TransFix group and 88.68 +/- 9.4 in the AperFix group (p < 0.022). There was no significance between the two groups in terms of laxity testing and complication rates. In the early postoperative period, satisfactory and comparable clinical results were achieved with the AperFix system when compared with cross-pin fixation in arthroscopic anterior cruciate ligament reconstruction.

[Asymmetric bilateral traumatic dislocation of the hip joint: a case report]. / Asimetrik iki tarafli travmatik kalça çikigi: Olgu sunumu.

Bilateral traumatic dislocation of the hip is a rare condition. Simultaneous asymmetric traumatic dislocation of the hip, one hip anterior and the other posterior, is even more unusual. This article reports a 21-year-old male patient with asymmetric bilateral dislocation of the hip joint, injured due to a landslide during a canal excavation. The patient was treated conservatively and evaluated according to Thompson and Epstein clinical and radiographic criteria after a follow-up period of 10 years and six months. The clinical result was perfect and radiographical result was good. We determined that our case had occurred as a result of a mechanism that has not been previously published in the literature and evaluated it from this point of view.

Clinical results of intramedullary nailing following closed or mini open reduction in pediatric unstable diaphyseal forearm fractures.

OBJECTIVES: We compared the clinical results of open reduction with a mini incision and closed reduction in pediatric unstable diaphyseal forearm fractures treated with intramedullary nailing. METHODS: We retrospectively evaluated 45 children who were treated with intramedullary nailing for unstable middle third diaphyseal forearm fractures. Before intramedullary nailing, 24 patients (group 1; 5 girls, 19 boys; mean age 10 years; range 5 to 14 years) underwent open reduction with a mini incision, and 21 patients (group 2; 5 girls, 16 boys; mean age 11.5 years; range 8 to 13 years) underwent closed reduction. There were 16 closed, seven Gustilo-Anderson type 1, and one type 2 open fractures in group 1, and 15 closed and six type 1 open fractures in group 2. The mean time to surgery was 5 days (range 1 to 20 days) in group 1, and 3.1 days (range 1 to 5 days) in group 2. Rush rods or Kirschner wires were used for fixation. In group 1, both radius and ulna were fixed in all the patients, whereas fixation involved both bones in 18 patients, and only ulna in three patients in group 2. Functional results were evaluated according to the criteria of Price et al. The mean follow-up period was 33 months (range 12 to 89 months) in group 1, and 37 months (range 14 to 52 months) in group 2. RESULTS: Union was obtained in a mean of 7.1+/-1.0 weeks (range 6 to 9 weeks) in group 1, and 6.5+/-1.0 weeks (range 6 to 10 weeks) in group 2. The implants were removed after a mean of 7.2+/-1.7 weeks (range 6 to 10 weeks) in group 1, and 8.1+/-0.4 weeks (range 8 to 10 weeks) in group 2. The two groups differed significantly with respect to union and implant removal times (p=0.036 and p=0.002, respectively). According to the criteria of Price et al., the results were excellent in 19 patients (79.2%) and 18 patients (85.7%), and good in five patients (20.8%) and three patients (14.3%) in group 1 and 2, respectively. There was no significant difference between the functional results of the two groups (p>0.05). Complications showed a similar profile in the two groups, being one major (4.2%) and seven minor (29.2%) in group 1, one major (4.8%) and eight minor (38.1%) in group 2. None of the patients had complications such as limb-length discrepancy, epiphyseal damage, angular or rotational deformity, synostosis, or limited elbow or forearm range of motion. CONCLUSION: Closed reduction or open reduction with a mini incision before intramedullary nailing yield similar functional results, with a similar complication profile in the treatment of pediatric unstable diaphyseal forearm fractures.

The three portal (including transpatellar tendon portal) versus two portal technique in the arthroscopic menisectomy procedure for isolated medial bucket-handle type meniscal tears.

OBJECTIVES: The aim of this study is to evaluate the efficacy of the central (transpatellar tendon) portal technique for the treatment of isolated medial bucket-handle type meniscal tears with the arthroscopic menisectomy procedure. PATIENTS AND METHODS: In this study, fifty patients with isolated medial bucket-handle type meniscal tears were evaluated. They were divided into two groups with 25 patients in each group. In the first group, the three portal (including central portal) technique was used and in the second group, the two portal technique was used. The results of the two groups were compared in terms of (i) operation times; (ii) changes in Insall-Salvati ratios postoperatively; (iii) postoperative Cincinatti scores; (iv) quadriceps muscle strengths; (v) the presence of anterior knee pain and; (vi) complication rates, in order to determine the significance of adding a central portal to the standard anterolateral and anteromedial portals in the menisectomy procedure. RESULTS: There was no significant difference between the two groups in terms of Cincinnati clinical scores, quadriceps muscle strenghts and complication rates. However, the operation time values of the first group were significantly shorter than the second group (p<0.001). The postoperative changes in Insall-Salvati ratio values were significantly higher in the first group than the second group (p<0.002). This results show us that the first group had a significant decrease in patellar tendon length whereas the second group had no change in size postoperatively. CONCLUSION: We suggest that the use of the central portal for viewing and instrumentation is a safe and quick technique in the menisectomy procedure for medial bucket-handle type meniscal tears, due to its unexpected lower complication rates and shorter operation times. While it causes patellar tendon shortening, this does not effect the clinical outcomes.

[The relationship between anterior knee pain occurring after tibial intramedullary nailing and the localization of the nail in the proximal tibia]. / Tibia kiriklarinin intramedüller çivi ile tedavisi sonrasi görülen diz önü agrisinin proksimal tibiadaki çivi yerlesimi ile iliskisi.

OBJECTIVES: We investigated the relationship between the development of postoperative anterior knee pain and the location of the nail in the proximal tibia in patients treated with locked intramedullary nailing for tibial diaphyseal fractures. METHODS: Thirty patients were selected among those who underwent locked intramedullary nailing for tibial diaphyseal fractures, with exclusion of all other factors that might be associated with postoperative anterior knee pain. In all the patients, intramedullary nailing was performed using the transtendinous approach and both proximal and distal locking. The patients were evaluated in two groups: 10 patients (3 women, 7 men; mean age 38 + or - 14 years) had anterior knee pain, whereas 20 patients (5 women, 15 men; mean age 35 + or - 12 years) did not. The distances from the nail to the tibial plateau and anterior tibial cortex were measured on the lateral x-rays after a mean follow-up of 56.6 months and 45.2 months in patients with and without anterior knee pain, respectively. RESULTS: The two groups were similar with respect to gender and follow-up period (p>0.05). The mean distances from the nail to the tibial plateau and anterior tibial cortex were -11.5 + or - 7.9 mm and 3.7 + or - 5.4 mm, respectively, in patients with anterior knee pain. The corresponding distances were -8.8 + or - 7.3 mm and 6.5 + or - 4.7 mm in patients without knee pain. Neither of the distances showed a significant difference between the two groups (p>0.05). CONCLUSION: Our findings suggest that the distances from the nail to the tibial plateau and anterior tibial cortex do not have any role in the development of postoperative anterior knee pain.

A comparison of percutaneous and mini-open techniques of Achilles tenotomy: an experimental study in rats.

PURPOSE: To investigate the effect of Achilles tenotomy performed percutaneously and by mini-open methods on tendon healing and final strength. MATERIALS AND METHODS: In two groups, each consisting of 14 rats, percutaneous and mini-open techniques in Achilles tenotomy were compared in terms of biomechanical, histological and gross properties. RESULTS: In the gross evaluation, it was observed that an obvious thickening and adhesion to the subcutaneous tissue of the healing tendon were observed in nearly all rats in which the mini-open technique was performed. In the biomechanical analysis, there was no significant difference between percutaneous and mini-open groups and between operated and intact Achilles tendons in both groups, in terms of tendon strength (P > 0.05). In the histological evaluation, irregularity in the parallel pattern of the collagen fibres, emergence of a non-specific collagenous tissue formation and infiltration of mild mononuclear inflammatory cells were reported. These changes were more marked in the rats in which the percutaneous technique was performed. CONCLUSION: Mini-open technique for Achilles tenotomy may be considered as an alternative method of treatment to apply the tenotomy technique in a secure way. CLINICAL RELEVANCE: There are two basic advantages of Achilles tenotomy performed by the mini-incision open technique: (1) a complete tenotomy is guaranteed, as it has to be in the original Ponseti technique, (2) iatrogenic neuro-vascular injury risk is nearly completely avoided due to the subparatenon exploration of the tendon and direct visual observation during the transection. The mini-open technique may only be used in cases in which a vascular compromise is clinically suspected or confirmed by Doppler ultrasonography and/or arteriography. On the other hand, the technique may be performed in all cases routinely by the choice of the surgeon.

Clinical importance of femoral and tibial tunnel localizations in arthroscopic anterior cruciate ligament reconstruction.

OBJECTIVES: The aim of this study is to evaluate the effect of femoral and tibial tunnel localizations on knee functions after arthroscopic single bundle anterior cruciate ligament (ACL) reconstruction and to contribute to the definition of the ideal tunnel localizations for the best results. PATIENTS AND METHODS: Thirty knees of 30 patients (29 males, 1 female; mean age 28.4 years; range 20 to 43 years) who underwent hamstring autograft reconstruction with the transfemoral fixation technique due to isolated complete rupture of the ACL were retrospectively evaluated. All of the operations were performed by the same surgeons and in the same institution. Tunnel localizations were defined according to the Harner Quadrant method in the post operative period. Mean follow-up period was 19.6 months and postoperative Lysholm knee scores and joint range of motion values were noted. The correlation between tunnel parameters and the scores were statistically evaluated. RESULTS: When all parameters were considered it was found out that the tunnel localizations in the sagittal tibial plane solely and independently had a significant effect on knee functions. CONCLUSION: It was concluded that especially the tibial tunnel located sagittally in the anterior second half of the plateau improves the knee functional scores after ACL reconstruction.

[The effect of abductor hallucis tendon release on residual adductus deformity in the surgical treatment of congenital clubfoot]. / Dogustan çarpik ayak cerrahi tedavisinde abdüktör hallusis tendon gevsetmesinin cerrahi sonrasi adduktus deformitesi üzerine etkisi.

OBJECTIVES: We evaluated the effect of abductor hallucis (AH) tendon release on residual adductus deformity in the surgical treatment of congenital clubfoot. METHODS: The study included 35 patients with congenital clubfoot. Thirteen patients (group 1, 21 feet) underwent classical complete subtalar release, while 22 patients (group 2, 31 feet) underwent the same treatment combined with AH muscle release by stripping it plantarward and transecting it distally. The mean age was 19.4 months (range 13 to 39 months) in group 1, and 13.5 months (range 11 to 25 months) in group 2. The mean follow-up period was 55.5 months (range 36 to 77 months) in group 1, and 24.7 months (range 10 to 37 months) in group 2. Radiographic assessments were made on preoperative, early postoperative, and final radiographs for the anteroposterior talo-first metatarsal angle and calcaneocuboid relationship, and for the anteroposterior naviculometatarsal angle and talonavicular relationship on final radiographs. RESULTS: Both groups showed significant improvement in the anteroposterior talo-first metatarsal angle in the early postoperative period (p<0.001); however, early and late postoperative talo-first metatarsal angle did not differ significantly both within groups and between groups (p>0.05). The anteroposterior naviculometatarsal angle was 95.3 degrees in group 1, and 96.7 degrees in group 2. The anteroposterior naviculometatarsal angle and talonavicular subluxation were similar in the two groups (p>0.05). The early and late postoperative calcaneocuboid relationship showed significant improvement in both groups, without a significant difference between the groups (p>0.05). CONCLUSION: It seems that release of the AH muscle does not affect the incidence of postsurgical residual adduction deformity in the surgical treatment of congenital clubfoot.