A new modification of the Trapdoor Procedure without surgical hip dislocation in the management of patients with osteonecrosis of the femoral head: A retrospective case series.

OBJECTIVE: The aim of this paper was to investigate the mid-term results of a modified Trapdoor procedure that can allow grafting of the femoral head without surgical hip dislocation in the management of patients with osteonecrosis of the femoral head. METHODS: 16 hips of 12 patients (7 female, 5 male; mean age = 38.5 ± 10.7) surgically treated by the new modification of Trapdoor procedure were retrospectively reviewed and included in the study. Based on the Association Research Circulation Osseous (ARCO) classification system, seven hips (43.7%) were stage 2, and nine hips (56.3%) were stage 3. The mean follow-up was 48.4 ± 25.7 months (range = 12-107). All the patients were evaluated postoperatively at the 6th week, 3rd month, 6th month, 1st year, and annually thereafter until their final follow-up. Clinical assessment was performed using the Harris Hip scoring (HHS) system, Non-Arthritic Hip score (NAHS) and Visual analogue pain scale (VAS). At the final follow-up, degenerative changes were examined according to the Kellgren-Lawrence scale. RESULTS: ThemeanHHS increased from53.43 ± 9.0 (range = 36-67) preoperatively to 83.81 ± 6.1 (range = 72-95) at the final follow-up (P < 0,001). Themean NAHS increased from 51.5 ± 8.2 (range = 36.25-61.25) preoperatively to 86 ± 3.2 (range = 81.5-90) (P < 0,001) at the final follow-up. The mean preoperative VAS decreased from 7.85 ± 0.9 (range = 6.45-9.5) to 3.05 ± 0.9 (range = 1.6-5.2) (P < 0,001) at the final follow-up. 13 hips demonstrated 80 and higher scores according toHHS. In the remaining three hips (ARCOstage 3), the mean postoperative HHS, NAHS, and VAS scores were 76, 82, and 3,2 respectively. According to Kellgren-Lawrence scale, three hips (18,75%) were determined as grade 0, 10 hips (62.5%) as grade 1, and 3 hips (18.75%) as grade 2. CONCLUSION: The Modified Trapdoor procedure without surgical hip dislocation seems to be a suitable technique with favorable clinical outcomes for the treatment of ARCO stage 2 and stage 3 osteonecrosis of the femoral head. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Longitudinal Epiphyseal Bracket as an Overlooked Etiology of Congenital-Residual Hallux Varus: A Case Report.

Longitudinal epiphyseal bracket is a rare ossification disorder of the short tubular bones. The affected bone becomes deformed as a result of the bracket. The normal growth pattern cannot occur, and when it affects the first metatarsal bone, hallux varus may develop with the abnormal growth pattern. We present such a 6-year-old patient who had undergone surgery at 6 months of age for hallux varus and polydactyly. The deformity had worsened gradually after the initial operation because of the overlooked longitudinal epiphyseal bracket. The patient was treated with surgical excision of the epiphyseal bracket, with corrective medial open wedge osteotomy and split transfer of the extensor hallucis longus tendon. The result was excellent at the 20-month follow-up. At an early age, patients who present with hallux varus must be checked for the epiphyseal bracket, which can be invisible on radiographs because of the chondral structure. Untreated or overlooked patients with epiphyseal bracket will need revision operations for recurrent deformities.

Prevalence estimation and familial tendency of common forefoot deformities in Turkey: A survey of 2662 adults.

OBJECTIVE: This survey was designed to evaluate the prevalence estimations of HV, bunionette, hammertoe as well as their relations to shoe wearing and also familial tendency, in Turkey. MATERIAL AND METHODS: Two thousand six hundred sixty two volunteers (1615 females and 1047 males) with a mean age of 34.15 ± 14.23 (range; 18 to 96) years were asked to answer the predetermined questionnaire between January and June, 2016. Hallux valgus, hammertoe and bunionette images were provided as references and every adult participant without any known forefoot problems or past forefoot surgery history was asked to rate his/her foot and to respond the questions about family history and shoe wearing habits. Responses were statistically analyzed. RESULTS: The prevalence estimations of hallux valgus, bunionette and hammertoe were calculated as 54.3%, 13.8% and 8.9% and positive family history rates were 53.2%, 61.2% and 56.1%, respectively. All three deformities were more common in females than in males (p < 0.001). Nonetheless the older age group reported significantly higher prevalence rates for only HV (p < 0.001). Likewise, among the three deformities, females reported a higher rate of positive family history only in HV compared to men (p < 0.001). Constricting shoe wear was found to affect HV incidence in women (p < 0.001) and bunionette incidence in both sexes (p < 0.01). CONCLUSION: This study concludes that forefoot deformities are common with high familial tendency. Hence it is worthwhile to work on molecular genetics and this may enable the anticipation of forthcoming deformities in order to take early action in prevention, in nearly the half of the population.

The results of Scarf osteotomy combined with distal soft tissue procedure are mostly satisfactory in surgical management of moderate to severe hallux valgus.

BACKGROUND: Intrinsically stable diaphyseal osteotomy gained popularity in recent years for symptomatic hallux valgus deformities. In this study, Scarf osteotomy results, in surgical management of moderate to severe hallux valgus, are presented. METHODS AND PATIENTS: Study group consisted of 40 feet of 32 (28 females, four males) patients surgically managed by Scarf osteotomy between September 2009 and 2011, with a mean age of 52,98 (range, 31-75) years at the time of surgery. Patient satisfaction and VAS were used for subjective evaluation while for objective measures AOFAS score, first metatarsophalangeal joint ROM and radiological measurements (intermetatarsal, hallux valgus and distal metatarsal articular angles) were evaluated. RESULTS: Mean follow-up period was 38 (range, 24-60) months. Sixteen feet (40%) were reported as very satisfied, 19 (47,5%) as satisfied and the remaining five (12,5%) as unsatisfied resulting with a total of 35 (87,5%) satisfaction. The mean preoperative VAS and AOFAS forefoot scores improved from 8,13±0,791 to 2,68±1,228 (p=0,0001) and from 58,25±6,15 to 78,25±8,13 (p=0,0001) on the final follow-up, respectively. The postoperative change of first metatarsophalangeal joint ROM was not statistically significant (p=0,281). On the radiological evaluation; intermetatarsal and hallux valgus angles improved from a mean value of 14,77±1,76 to 8,13±1,52° (p=0,0001) and from 35,28±5,86 to 20,10±5,55° (p=0,0001), respectively. Distal metatarsal articular angle did not show any statistically significant change (p=0,195). CONCLUSION: Scarf osteotomy combined with distal soft tissue procedure is a technically demanding procedure. The osteotomy is intrinsically stable and the correction power is high and the results are mostly satisfactory.

Arthroscopic-assisted retrograde mosaicplasty for an osteochondral defect of the femoral head without performing surgical hip dislocation.

Osteochondral autograft transplantation (mosaicplasty) for the osteochondral defects of the femoral head is generally performed with safe dislocation of the hip joint. Here, we present a 27-year-old male patient who had a symptomatic osteochondral defect of the femoral head and underwent mosaicplasty applied by hip arthroscopy without surgical hip dislocation. The preoperative radiological evaluation showed a focal osteochondral defect on the weight-bearing surface of the femoral head. With the assistance of hip arthroscopy, the defect area was reconstructed with osteochondral plug, which was taken from the ipsilateral knee, inserted in a retrograde fashion, and positioned with the spherical surface of the femoral head cartilage under fluoroscopic and arthroscopic control. At the final follow-up (26 months postoperatively), he had full range of motion (ROM) without pain and radiographic evaluation showed near complete incorporation of the graft with preservation of the native joint space. Mosaicplasty can be applied in a retrograde fashion with the assistance of hip arthroscopy without using surgical hip dislocation and may be an alternative treatment option for the osteochondral defects of the femoral head in young patients.

Pedobarographic Analysis in Total Knee Arthroplasty.

Pedobarographic gait analysis is a useful tool for the determination of loading distributions and alterations on the lower extremity and their reflection on the foot sole after many orthopaedic surgical applications. To date, there have been no studies evaluating the relationship between component alignment and changes of pedobarographic gait analysis in total knee arthroplasty (TKA). We aimed to investigate the effects of TKA and prosthetic alignment on the distribution of pedobarographic parameters. Quantitative gait patterns of 47 patients were prospectively evaluated by using pedobarography 1 week before surgery and at the seventh month, on average, postoperatively. Component positions were assessed, and all applications were divided into three groups according to tibial component position as varus, neutral, and valgus. Pedobarographic results were compared between pre- and postoperative values for all applications and compared among the groups. Mean postoperative tibiofemoral angle was 5.4 degrees in valgus, and preoperative knee scores were markedly improved postoperatively. The range of tibial component alignment changed between 1 and 4 degrees in the varus and valgus groups. Plantar loading parameters (force and pressure) were significantly decreased in all operated knees, especially in forefoot and midfoot. In varus tibial components, plantar loading values decreased in midfoot and hindfoot. However, in the neutral and valgus groups, similar alterations of plantar loadings were obtained, which included decreasing in forefoot and midfoot with significant increase in hindfoot. Plantar loading distribution changed statistically significantly after TKA despite good clinical and radiographic results. Tibial component alignment was also responsible for plantar loading distribution. Tibial components in varus position create different foot loading characteristics compared with neutral and valgus aligned components. Pedobarographic evaluation in TKA allows clinicians to obtain a proper understanding of abnormal gait caused by component malposition.

Proximal femoral nail shows better concordance of gait analysis between operated and uninjured limbs compared to hemiarthroplasty in intertrochanteric femoral fractures.

PURPOSE: The purpose of this study was to compare the results of pedobarographic gait analysis between the patients treated by proximal femoral nail or bipolar partial hemiarthroplasty due to intertrochanteric fractures. METHODS: Thirty-seven patients with a minimum 1-year follow-up who had been operated for intertrochanteric fractures were evaluated clinically, radiologically and with pedobarographic gait analysis. Proximal femoral nail had been performed to 21 patients (group A), whilst 16 patients had been operated by partial bipolar hemiarthroplasty (group B). Pedobarographic analysis was performed by measuring plantar pressure, force and contact area values in both static and dynamic manner. Pedobarographic results of operated limb were compared among groups. Same data's also were compared between operated and uninjured limbs in each group to determine any asymmetry on weight-bearing. RESULTS: Average follow-up period in group A and group B was 36 (12-56) and 30 (12-48) months, respectively. There were no statistically significant differences among groups in terms of age, gender, body mass index, type and side of fracture, follow-up period, leg length discrepancy and postoperative hip scores. When the pedobarographic results of operated limb were compared, group B showed much more plantar force and pressure values than group A, on both static and dynamic evaluations. If the evaluation was taken into consideration to comparison of pedobarographic results between operated and uninjured limbs in each group, we found asymmetry in static load bearing, caused by higher load on uninjured limb in both groups. However, there was no statistically significant asymmetry between operated and uninjured limbs in respect to dynamic pedobarographic parameters for patients in group A. On the contrary, operated limbs in group B exposed much more plantar force and pressure values than uninjured limbs, which indicated asymmetric weight-bearing on dynamic evaluation. CONCLUSIONS: Assessment of pedobarographic parameters can be another way of measuring the results of treatment in intertrochanteric fractures. Uninjured limbs of patients expose much more loading than operated limbs in postoperative static evaluation for both treatment options. However in dynamic evaluation, there is a better concordance of gait analysis between both limbs in patients operated by proximal femoral nail.

Modified Grice-Green subtalar arthrodesis performed using a partial fibular graft yields satisfactory results in patients with cerebral palsy.

The aim of this study was to report the experience with the use of a modified Grice-Green technique, which was performed using a partial subperiosteal fibular bone graft because of valgus unstable foot in children with cerebral palsy. Fifteen feet of 11 patients were evaluated on the basis of the appearance of the feet, clinical symptoms, and radiographic measurements. After an average follow-up duration of 24 (9-39) months, all feet showed satisfactory clinical and radiological results. Solid fusion and sustained correction took place in all feet. The gap at the donor site was bridged with new bone in all cases. No donor-site morbidity was detected. This modification of the Grice-Green technique can be used effectively in the correction of planovalgus foot in cerebral palsy.

Etiology of coxarthrosis in patients with total hip replacement.

OBJECTIVE: We aimed to find out the distribution of etiological factors in patients who had total hip replacement for coxarthrosis. METHODS: The medical records of the 965 hips of 886 patients operated with total hip replacement between 2001 and 2012 in two separate arthroplasty clinics were analyzed by two separate senior surgeons. Each patient's pre- and postoperative X-rays and demographic data such as gender, age, side and probable etiologic factors were noted. RESULTS: Six hundred and eighty-four patients were women and 202 were men. The mean age were 62.7±14.3 (range: 16 to 91) in women, 58.8±17.1 (range: 25 to 91) in men. 52.1% of the surgeries were performed on the right side, 39% on the left, and 8.9% bilaterally. In women 36.2% of the cases were primary coxarthrosis, while the etiology was developmental dysplasia of the hip (DDH) in 43.5% of the cases, avascular necrosis in 10%, romatoid diseases in 7%, slipped capital femoral epiphysis in 5%, posttraumatic coxarthrosis in 3.9%, pathologic coxarthrosis in 1.9%, and Perthes sequel in 1.7%. In men, 24.4% of the cases were primary coxarthrosis, while the etiology was avascular necrosis in 21% of the cases, DDH in 17.6%, posttraumatic coxarthrosis in 16.8%, romatoid diseases in 10.9%, Perthes sequel in 4.2%, slipped capital femoral epiphysis in 2.5%, and pathologic coxarthrosis in 2.5%. The most common etiologic factor was DDH with a rate of 37.1%. CONCLUSION: Despite the heterogeneity of our study population, our results may reflect the distribution of coxarthrosis etiologies in Turkey. Developmental dysplasia of the hip appears to be the most frequent cause of coxarthrosis among the patients undergoing total hip replacement.

Can bone quality be predicted accurately by Singh index in patients with rheumatoid arthritis?

The aim of this study was to evaluate Singh index as a simple and inexpensive means of estimation of bone quality in patients with rheumatoid arthritis. Singh index evaluation was made on digital pelvis radiographs in 50 consecutive patients by three observers. Bone mineral density T scores of the spine and left proximal femur were assessed using dual energy X-ray absorptiometry. Singh index was correlated with densitometry measurements after grouping the patients as normal, osteopenia and osteoporosis. Intra- and interobserver agreements were evaluated by kappa correlations. Sensitivity, specificity, positive and negative predictive values and likelihood ratio's of Singh index were calculated. Both intra- and interobserver agreements were 0.71 (range, 0.69 to 0.72) on average. Singh index proved highly sensitive for the diagnosis of osteopenia at the proximal femur (91%) and spine (90%), whereas the specificity of Singh index for identifying of osteoporosis at the femoral neck (93%) and spine (91%) was higher than sensitivity. Predictive values for osteoporosis at the proximal femur and spine were acceptable and positive likelihood ratios of Singh index for osteopenia and osteoporosis at the proximal femur were 2.4 and 10.1, respectively. Singh index can identify osteoporosis with a high specificity in patients with rheumatoid arthritis. However, the patients who are graded as osteopenia by the Singh index should undergo further evaluation with dual energy X-ray absorptiometry.

An unusual cause of a cystic lesion with an osteochondral defect in the talus: intraosseous lipoma.

An intraosseous lipoma is a rare benign bone lesion that proliferates from mature lipocytes. It occurs most frequently in the lower limb, particularly in the calcaneus. The talus is an unusual location for this rare lesion. A review of the literature produced only two reports with talar intraosseous lipomas under the name of intraosseous lipomatosis, which described multiple lipomas in different areas. We describe a 38-year-old male patient who had an isolated intraosseous lipoma with an osteochondral defect in the talus and was treated with autologous osteochondral graft transplantation by medial malleolar osteotomy. He could walk with full weightbearing without any assistance at the end of 12 months. Intraosseous lipoma localized in the talus may be confused radiologically with other bone lesions, especially with unicameral bone cyst, if it is associated with an osteochondral defect. Autologous osteochondral graft transplantation is a successful treatment method for talar intraosseous lipoma.

Treatment of reverse oblique trochanteric femoral fractures with proximal femoral nail.

Treatment of reverse oblique trochanteric femoral fractures is still challenging. We present the results of our proximal nailing surgery performed for reverse obliquity intertrochanteric fractures using two lag screws and evaluated the quality of the reduction, operative time, complications and functional status of the patients. Fifteen patients with AO/OTA 31 A-A3 fractures were treated by proximal femoral nailing in our trauma centre. The mean Harris hip score was 74.66 (range 65-96) and the mean Barthel activity score was 15.71 (range 12-20). The mean duration of surgery was 48 minutes and the average consolidation time was 8.6 weeks. No intraoperative complications or postoperative technical failures and no stress shielding as evidenced by the lack of cortical hypertrophy at the level of the tip of the implant were detected. Intramedullary nailing with proximal femoral nails may be a good option in the treatment of reverse obliquity intertrochanteric fractures.

Early results of distal metatarsal osteotomy with K-wire fixation in the treatment of tailor's bunion.

OBJECTIVE: Tailor's bunion deformity is a lateral side bone and soft tissue prominence of the fifth metatarsal bone. The aim of our study was to assess the clinical and radiographic results of distal metatarsal osteotomies in patients with tailor's bunion deformity. METHODS: This study included 24 feet of 14 patients with tailor's bunion who were treated with distal metatarsal osteotomy of the 5th metatarsal between 2006 and 2009. The mean follow-up time was 24.45 (range: 12 to 47) months. Patients were evaluated clinically and radiographically, using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system with weight-bearing anteroposterior and lateral foot radiographs. RESULTS: Average AOFAS scores of the patients were 64.83 preoperatively and 91.62 at the final follow-up. Three patients had complications; avascular necrosis, delayed union, and superficial wound infection. CONCLUSION: Distal metatarsal osteotomy is a safe and easy treatment option for the painful tailor's bunion deformity and provides patient satisfaction rate of up to 96%.

Transosseous capsuloplasty improves the outcomes of Lindgren-Turan distal metatarsal osteotomy in moderate to severe hallux valgus deformity.

INTRODUCTION: Lindgren-Turan osteotomy used in hallux valgus deformity is a subcapital, transverse displacement osteotomy of the first metatarsal without any additional capsular repair. The aims of this study are to describe a transosseous capsuloplasty technique in this procedure and evaluate whether capsuloplasty would improve the clinical and radiological outcomes in patients with moderate to severe hallux valgus deformity. METHODS: Twenty-three feet operated by Lindgren-Turan osteotomy (Group B) and 25 feet operated by the same osteotomy combined with transosseous capsuloplasty (Group A) were evaluated retrospectively for the correction of the hallux valgus, intermetatarsal and distal metatarsal articular angles, sesamoid reduction, American Orthopaedic Foot and Ankle Society (AOFAS) Clinical Rating Scale as well as patient satisfaction. The mean postoperative follow-up was 14 (range 12-28) months. RESULTS: All radiological parameters improved considerably as a result of both groups. However, postoperative improvements in intermetatarsal and distal metatarsal articular angles were greater in Group A. Complete reduction of medial sesamoid was achieved in 52% of patients in Group A, whereas 17.4% of patients in Group B had complete reduction. AOFAS scores and number of patients with complete satisfaction in Group A were significantly greater than that in Group B. CONCLUSION: Better clinical and radiological outcomes can be achieved in patients with moderate to severe hallux valgus deformity operated by Lindgren-Turan distal metatarsal osteotomy, when it combines with transosseous capsuloplasty.

"Floating arm" injury in a child with fractures of the proximal and distal parts of the humerus: a case report.

INTRODUCTION: Simultaneous supracondylar humerus fracture and ipsilateral fracture of the proximal humerus in children is rare. CASE PRESENTATION: A 10-year-old Turkish boy with an extension type supracondylar humerus fracture and ipsilateral fracture at the proximal metaphyseal-diaphyseal junction of the humerus was treated by closed reduction and percutaneous Kirschner wire fixation. Closed reduction was performed using a Kirschner wire as a "joystick" to manipulate the humeral shaft after some swelling occurred around the elbow and shoulder. CONCLUSION: The combination of fractures at the proximal and distal parts of the humerus can be termed as "floating arm" injury. Initial treatment of this unusual injury should be focused on the supracondylar humerus fracture. However, closed reduction can be difficult to perform with the swelling around the elbow and shoulder. A temporary Kirschner wire can be used as a "joystick" to fix and reduce the fracture.

Treatment of Tönnis type II hip dysplasia with or without open reduction in children older than 18 months: a preliminary report.

PURPOSE: In this study, we aim to investigate whether the hip with Tönnis type II dysplasia in children older than 18 months can be treated without open reduction. METHODS: In our study, 47 hips (47 patients) with type II developmental dysplasia of the hip according to the Tönnis classification were treated by a combination of open reduction through an anterolateral approach with iliopsoas tenotomy followed by innominate osteotomy and capsulorrhaphy or iliopsoas tenotomy followed by innominate osteotomy. The patients with open reduction constitute the open Salter group (32 hips), while the rest of the patients with innominate osteotomy alone constitute the closed Salter group (15 hips). The acetabular index (AI) and Smith's c-b and h-b index were assessed on the preoperative, immediate postoperative and final follow-up hip X-rays. RESULTS: There were no statistically significant differences related to sex distribution, age and postoperative follow-up time between the patients of each group. There was also no statistically significant difference between the preoperative AI of the open and closed Salter osteotomy groups. Overall, 80% of hips with open reduction had Smith's c-b ratio greater than the value of 1 and h-b ratio lower than the value of 0.05. CONCLUSION: The preoperative c-b index of the open osteotomy group was statistically greater than the c-b index of the closed osteotomy group and the preoperative h-b index of the open Salter group was statistically smaller than the h-b index of the closed Salter group, which means that most of the hips in the open osteotomy group are more in a lateralised and superior position compared to the closed osteotomy group. To us, there exists a subgroup of hips with less lateralisation and superior displacement according to the Smith's c-b and h-b ratio in Tönnis type II hip dysplasia. These hips might be less amenable to capsulorrhaphy because of the lower capsular instability and treatment may be done with closed reduction after iliopsoas tenotomy with Salter osteotomy in this select group of patients.

A new radiographic measurement method for evaluation of tibial torsion: a pilot study in adults.

UNLABELLED: Computed tomography (CT) frequently is used to determine torsional abnormalities. However, its use in clinical practice may be limited. We present a new method for measuring tibial torsion using conventional radiographs. We compared the method with several clinical methods and with CT measurement in 44 lower extremities of 25 subjects. The radiographic method agreed well with all of the clinical methods, and this agreement was better than agreement between CT and clinical examination. The best agreement was between thigh-foot angle and the radiographic method. The proposed radiographic measurement is a practical method for evaluation of tibial torsion in outpatient clinics without the need for specialized equipment. LEVEL OF EVIDENCE: Level II, diagnostic study.

Successful treatment of bilateral open calcaneal fractures with concomitant lower extremity injuries: A case report.

Open calcaneal fractures are high morbidity injuries and the risk of complications depends on the concomitant injuries, on the size and the position of the traumatic wound. A 53-year-old male patient with bilateral open calcaneal fractures and associated concomitant lower extremity injuries such as subtalar dislocation, talonavicular dislocation and open distal tibial metaphyseal fracture was immediately operated by percutaneous Kirschner wire fixation combined with external fixators. He was able to walk with full weight bearing without any assistance at the end of the first postoperative year. Early aggressive debridement and irrigation followed by fixation with percutaneous Kirschner wires and external fixator can supply bony alignment in open comminuted calcaneal fractures associated with concomitant lower extremity injuries and should be considered for the healthy and active patients before primary arthrodesis.