A new measurement method in Graf technique: prediction of future acetabular development is possible in physiologically immature hips.

BACKGROUND: Universal ultrasound screening has led to overtreatment and higher follow-up rates than are found with clinical examination alone because of high incidence of physiologically immature hips (type IIa) in the first weeks of life. The ability to predict future acetabular development in physiologically immature hips (type IIa) would therefore help to reduce overtreatment and unnecessary follow-up. METHODS: We described the γ-angle to assess the femoral head coverage by the acetabular roof, which is measured between the baseline defined by Graf and the cartilaginous edge line connecting the inferior point of the iliac bone (lower limb) to the medial corner of the acetabular labrum. We retrospectively analyzed ultrasonographic findings of infants with developmental dysplasia of the hip diagnosed in our hospital and infants with normal hips screened in our hospital. Group 1 (35 hips) consists of type IIa hips at initial examination and went on to develop into dysplastic hips at follow-up. Group 2 (279 hips) consists of type IIa hips at initial examination and went on to develop into normal hips (type I) at follow-up. RESULTS: The γ-angles of type IIa hips that developed into type I hip at follow-up ranged between 77 and 82. The γ-angles of type IIa hips that developed into hip dysplasia ranged between 72 and 78. All type IIa hips that had γ-angles >78 degrees developed into normal hips. We also observed that all type IIa hips that had γ-angles <77 degrees developed into dysplasia. CONCLUSIONS: The amount of cartilage mass covering the femoral head, which is a part of the acetabular roof, can therefore provide information about future acetabular development. This paper describes a new method of measurement (the γ-angle) that assesses the extent of the cartilage coverage of the femoral head, which can predict acetabular development. Its use would decrease the rates of unnecessary follow-up and treatment. LEVEL OF EVIDENCE: Level II (development of diagnostic criteria on the basis of consecutive patients).

A comparison of ultrasonography and radiography in the management of infants with suspected developmental dysplasia of the hip.

The aim of this study was to determine the sensitivity and specificity of plain radiography in the detection of developmental dysplasia of the hip, using hip ultrasonography as a reference standard. A retrospective review was made in 44 infants ranging in age from 4 weeks to 50 weeks (mean age: 21.7 weeks). Both radiographic and ultrasonographic images were obtained for 86 hips. Radiography and ultrasonography were found to be significantly correlated in terms of classification of developmental dysplasia of the hip presence or absence (p < 0.0001, Fisher's exact test). With ultrasonography accepted as the standard for the diagnosis of developmental dysplasia of the hip, radiography had a sensitivity of 61% and a specificity of 87%. The results of this study suggest that the two imaging methods give similar overall results, but that low grade dysplasia detected on ultrasonography may go undetected on radiography.

Results of Tönnis-type acetabuloplasty in patients with developmental hip dysplasia.

AIM: The aim of this prospective study was to evaluate the outcome of open reduction and Tönnis acetabuloplasty as the first method of treating developmental dysplasia of the hip (DDH) in children in early childhood at walking age. MATERIALS AND METHODS: Between 2005 and 2009, 34 hips of 34 children were operated on with the aforementioned method. Mean age was 25.6 (range 12-44) months, and mean follow-up was 3.6 years. During the follow-up period ,the hips were evaluated using the acetabular index and for development of avascular necrosis and redislocation. Functional evaluation was also conducted. RESULTS: Clinically, 97.3 % of patients had excellent and good results. The acetabular angle decreased from 45° preoperatively to 21° early postoperatively and at the last follow-up had improved to 18°. In two hips, type 2 avascular necrosis developed. Hip instability was not observed, and no additional surgery was performed. CONCLUSION: Tönnis acetabuloplasty is a powerful tool to increase primary stability of the hip when acetabular coverage is inadequate in DDH. Besides its acute correction ability, when performed properly, it has no unwanted effects on acetabular growth. As an isolated procedure or as a part of combined open reduction and/or femoral osteotomy, Tönnis type acetabuloplasty is a safe and effective method.

[Superfluous computed tomography utilization for the evaluation of the pelvis and spinal column in an orthopedic emergency department]. / Acil ortopedi ve travmatoloji polikliniginde omurga ve pelvis degerlendirmesi için gereksiz bilgisayarli tomografi kullanimi.

OBJECTIVES: This study was designed to investigate the frequency of requests for computed tomography (CT) examination of the spinal column and pelvis in our emergency orthopedic department, the reasons of requests, and the rates of positive and negative CT examinations. METHODS: We retrospectively reviewed patients for whom a request for CT examination was made by the emergency orthopedic department within a year (September 2005- 2006). The reasons for CT requests, findings in CT reports, and age and sex of the patients were recorded. Findings unrelated and related to the original request denoted a negative and positive CT examination, respectively. RESULTS: Of 24,378 admissions to our emergency orthopedic department, a CT scan was requested in 1,295 patients (5.3%). In 817 patients (63.1%), CT examination involved the pelvis or the spinal column. Of these, 418 CT scans (51.2%) yielded a negative result. The mean age of the patients with a negative CT scan was significantly lower than those having a positive CT scan (40.7 vs 45.1 years; p=0.001). There was no significant difference with respect to sex between patients having negative and positive CT findings (p=0.670). Compared to pelvis CT scans, the frequency of negative CTs was significantly higher for spinal column examinations (p<0.001). The incidence of negative CT scans for upper thoracic and cervical vertebrae was significantly higher than that found for lower thoracic and lumbar regions (p<0.001). CONCLUSION: The high incidence of negative CT scans documented for pelvic and spinal column examinations underlines the need for measures to avoid superfluous CT requests in emergency departments.

[Comparison of plate-screw fixation and intramedullary fixation with inflatable nails in the treatment of acute humeral shaft fractures]. / Akut humerus cisim kiriklarinin cerrahi tedavisinde plak vida ile sisebilen intramedüller çivi yöntemlerinin karsilastirilmasi.

OBJECTIVES: We compared the results of plate-screw fixation and intramedullary fixation with inflatable nails for the treatment of acute humeral diaphyseal fractures. METHODS: The study included 34 patients (20 females, 14 males; mean age 36.4 years; range 18 to 62 years) who were selected from patients treated with plate-screw fixation or inflatable intramedullary nails. The groups were matched for age, sex, severity of fracture, and the type of humeral fracture. Eighteen fractures were treated in each group. Classification of humeral fractures and open fractures were made according to the AO and Gustilo-Anderson systems, respectively. Functional evaluations were made at postoperative six and 12 months using Constant shoulder and Mayo elbow performance scores. All the patients were administered the Short-Form 36 (SF-36) questionnaire at 12 months. The two groups were compared with respect to operation time, perioperative need for blood transfusion, time to union, complications, and shoulder and elbow functions. RESULTS: The mean operation time was significantly shorter (25.3 min vs 66.1 min; p<0.001) and the need for blood transfusion was significantly less (p=0.001) with inflatable intramedullary nails. Constant shoulder and Mayo elbow scores did not differ significantly between the two groups. Implant failure was only encountered with plate-screw fixation in three patients. Union problems were observed in five patients (3 plate-screw, 2 intramedullary nail). Following plate-screw fixation, two patients developed superficial infection, two patients developed transient radial paralysis. CONCLUSIONS: Inflatable intramedullary nails can be used safely in the treatment of acute humeral diaphyseal fractures without increasing union problems and complications.

Alternative reliable techniques in femoral torsion measurement.

The clinical and conventional bi-planar determinations of femoral torsion were compared with the tomographic technique, the reliability of which was confirmed. Femoral torsions were measured with the trochanteric prominence angle test, the sinus-wave bi-planar conventional radiographic technique, the modified Hermann bi-planar conventional radiographic technique and the limited three-dimensional volumetric tomography technique in 34 femora of 17 patients. There was a strong correlation between the modified Hermann and the limited tomography techniques for 14 intact and 20 fractured femora. If limited three-dimensional volumetric tomography cannot be obtained, the modified Hermann bi-planar conventional radiographic technique must be used in patients who have scarring about the proximal femur and obesity. Otherwise use of the trochanteric prominence angle test is much more cost-effective and is as accurate as the limited three-dimensional volumetric tomography technique.

[Importance of lumbar vertebra transverse process fractures in multitrauma patients who had undergone emergent laparotomy]. / Acil laparotomi yapilan multitravmali hastalarda lomber vertebra transvers çikinti kiriklarinin önemi.

BACKGROUND: To evaluate the incidence and importance of lumbar vertebra transverse process fractures in polytraumatized patients who had undergone emergent laparatomy, and to find out the relevant risk factors. METHODS: The medical records of 312 laparotomized trauma patients who referred to our emergency department between January 2001 and January 2002 were retrospectively assessed. Hundred and six cases who met inclusion criteria were investigated. Data relevant to the trauma, demographics, hemoglobine levels, additional system traumas, complications were recorded. Correlations between collected data and the fractures were investigated. Results were evaluated statistically using SPSS 11,0 software package program. RESULTS: Lumbar vertebra transverse process fractures were detected in 58,5 % of the cases. They were more frequently encountered in women, elderly and after falls or traffic accidents.. Abdominal organ injuries were more common in these cases. These fractures are associated with hepatic and splenic injuries. Their presence also increases the risk of vertebra corpus fractures seven fold. CONCLUSIONS: Lumbar vertebra transverse process fractures usually occur after higher energy traumas They must be evaluated as serious findings which might lead to potential organ injuries. Once these fractures were detected in trauma patients, every attempt should be made to exclude probably fatal and more serious additional organ injuries.

[The effect of long- or short-arm casting on the stability of reduction and bone mineral density in conservative treatment of Colles' fractures]. / Colles kiriklarinin konservatif tedavisinde kisa veya uzun kol alçilamanin kemik mineral yogunlugu ve redüksiyon üzerine etkisi.

OBJECTIVES: We evaluated the effect of long- or short-arm casting on the stability of reduction and bone mineral density (BMD) in the forearm in patients treated conservatively for Colles' fractures (CF). METHODS: Eighty-three patients (48 females, 35 males; mean age 53 years; range 30 to 76 years) with an isolated unilateral CF underwent closed reduction followed by a randomly assigned long-arm (n=44) or short-arm (n=39) casting. Fractures were classified according to the Frykman's system. After reduction, radiographs of both forearms were taken, on which radial height and inclination, and volar tilt were measured and assessed according to the criteria by Sarmiento et al. In the first week, BMD measurements were made on the unaffected side to obtain reference values from four sites of the forearm, namely ultradistal, 1/3 proximal, middle diaphysis, and total. Following removal of the casts (mean 45.3 days; range 40 to 55 days), radiographic and BMD assessments were repeated. Osteoporosis was defined according to the criteria of the World Health Organization. RESULTS: The two casting groups were similar with respect to age, sex, Frykman's classification, involved side, and the dominant extremity. Osteoporosis was detected in 20% according to the T scores. All the sites in the fractured forearm showed density losses, but the difference was significant only in the middle diaphysis (p<0.05). No significant relationship was found between BMD losses and the cast type. Angular measurements showed significant deterioration after union; however, none was found to be related to the cast type (p>0.05). CONCLUSION: Our results show that BMD losses and deterioration in reduction following treatment of CF occur irrespective of which type of casting is used.

[Short-term results of treatment of humeral and tibial fractures with new inflatable intramedullary nails]. / Sisirilebilen intramedüller çivi kullanilarak tedavi edilen humerus ve tibia diafiz kiriklarinda kisa dönem sonuçlar.

OBJECTIVES: We evaluated the effectiveness of a new inflatable intramedullary nail system in the treatment of tibial and humeral fractures. METHODS: The study included seven patients (4 men, 3 women; mean age 37.5 years; range 27 to 48 years) whose humeral or tibial fractures were treated by new inflatable intramedullary nails. Five fractures were in the tibial diaphysis; three were humerus fractures. One patient had bilateral involvement. All tibial fractures and one humeral fracture were fresh, whereas two patients presented with delayed union. Treatment consisted of closed reduction and antegrade intramedullary nailing, with the addition of bone grafting in delayed unions. The patients were evaluated with regard to operation duration, healing periods, complications, and final clinical and radiologic findings. The mean follow-up period was 15.3 months (range 12 to 20 months). RESULTS: Operation time for both tibial and humeral fractures was less than that with other internal fixation techniques. The need for fluoroscopic monitoring decreased appreciably, as well. Healing times were similar to those of other intramedullary nailing systems. No complications occurred related to the use of the inflatable intramedullary nail system. CONCLUSION: The use of inflatable intramedullary nails may have significant implications in selected fractures, allowing easier stabilization of long bone fractures and saving valuable operation time.

[Real angulation degree in fifth metacarpal neck fracture]. / Besinci metakarp boyun kiriginda gerçek açilanma degeri.

OBJECTIVES: This study investigated whether the confusion about the acceptable angulation value in fifth metacarpal neck fractures results from the hand radiographs taken at non-standard oblique position. MATERIALS AND METHODS: In this experimental study two Kirshner wires representing the intramedullary axis of the two fracture fragments were placed on a platform prearranged with an angle of 50 degrees between them. The radiographs of the wires were taken on the platform (horizontal) at angles of 0, 30, 45 and 60 degrees. The radiographs were taken without changing the cassette location and the position of the radiography device. RESULTS: The known volar angulation (50 degrees) was measured on the radiographs as 50, 36, 30 and 23 degrees, respectively. CONCLUSION: The main debate about the fifth metacarpal neck fracture is over the acceptable distal fragment volar angulation degree. This degree of angulation is between 30 and 70 degrees in the studies. The presence of such different and inaccurate results in the literature results from the use of non-standard oblique hand radiographs. Standardized radiographs are required in fifth metacarpal neck fractures.

Comparison of knee function after antegrade and retrograde intramedullary nailing for diaphyseal femoral fractures: results of isokinetic evaluation.

OBJECTIVE: To evaluate knee function in patients having femoral diaphyseal fractures treated with antegrade or retrograde intramedullary nail insertion. DESIGN: Prospective. SETTING: Level I referral center. PATIENTS AND METHODS: Seventy patients having 71 OTA 32 fractures were randomly allocated into 2 groups to be treated with either antegrade or retrograde intramedullary nails inserted with reaming. INTERVENTION: Antegrade nail in 41 fractures and retrograde femoral intramedullary nails in 30 fractures. MAIN OUTCOME MEASURES: Postoperative knee range of motion, Lysholm Knee Score, and isokinetic knee muscle function testing at least 6 months after documented fracture healing, minimum 1 year postoperatively. RESULTS: Groups had similar data with regard to demographics and injury patterns. Mean follow-up time was 44 (range: 25-80) months. Mean knee flexion angle was 132 and 134 degrees, and mean Lysholm Score was 84 and 83.1 in antegrade and retrograde groups, respectively (P = 0.893 and P = 0.701). Isokinetic evaluation revealed similar results for peak torque deficiencies at 30 and 180 degrees per second and total work deficiencies at 180 degrees per second (P > 0.05). Age affected the knee functioning as the higher the age of the patient is, the lower the Lysholm Score and knee flexion angle (r = -0.449, P = 0.0321 and r = -0.568, P = 0.001, respectively). CONCLUSIONS: Knee function seems to have similar clinical results after either antegrade or retrograde nail insertion for femoral diaphyseal fractures when knee range of motion, Lysholm Scores, and isokinetic knee evaluation are considered as outcome measures. With increasing patient age, a decrease in knee functioning should be anticipated in patients with femoral fractures treated with intramedullary nails regardless of technique.

[An alternative fixation method for the treatment of unstable distal clavicle fractures: locked distal radius plate]. / Distal klavikula ayrismali kiriklari için yeni bir tespit yöntemi: Kilitli distal radius uç plagi.

OBJECTIVES: Optimal surgical fixation method for displaced distal clavicle fractures should not impose limitations on neighboring joint movements. We evaluated the results of surgical treatment of displaced distal clavicle fractures using locked distal radius plates. METHODS: Displaced distal clavicle fractures of 14 consecutive patients (11 men, 3 women; mean age 30 + or - 9 years; range 19 to 51 years) were treated using open reduction and locked distal radius plates. Before final fixation, one patient underwent K-wire fixation with tension band at another center, resulting in nonunion. Except for two cases with late presentation, the mean time to surgery was 5.3 days (range 1 to 17 days). According to the Neer classification, fresh fractures were type II in 10 patients and type III in three patients. Shoulder examinations and functional evaluations were made at 3, 6, and 12 months postoperatively. Functional assessment included the Modified Shoulder Rating Scale and Constant score. RESULTS: All patients achieved full range of motion of the shoulder at six weeks postoperatively. The mean modified shoulder score was 18.7 + or - 1.5 and the mean Constant score was 95.4 + or - 3.0 at 12 months. None of the patients developed implant failure, loss of reduction, skin breakdown, or infection. CONCLUSION: In selected acute fractures and nonunions of the distal clavicle, excellent clinical results are easily achievable with locked distal radius plate fixation because it allows early shoulder movements without necessitating implant removal.

Results of triple arthrodesis: effect of primary etiology.

BACKGROUND: Severe disability originating from feet generally requires surgery. In addition to a number of other techniques, triple arthrodesis is still used to treat deformity and instability unresponsive to conservative measures. The aim of this study was to evaluate the results of the triple arthrodesis operation in two groups of patients with different primary etiologies and to identify the possible factors affecting the results. METHODS: During a 4-year period, triple arthrodesis was performed on 25 feet in 20 patients (average age 24.9 years). These patients were divided into two groups according to the primary etiology of the disability: neurogenic and nonneurogenic. Patients were evaluated with pre-and postoperative clinical examinations, American Orthopedic Foot and Ankle Society (AOFAS) Hindfoot and Ankle Scale, radiography, pedobarography, and a general health questionnaire (Short Form 36, SF-36). The need for orthotics and the effect of previous treatments on the end results were also evaluated. RESULTS: The preoperative average AOFAS score improved from 24 to 71 postoperatively. Preoperative AOFAS values of neurogenic cases were significantly lower than those of nonneurogenic cases. Postoperative AOFAS values were found to be lower in neurogenic cases (64.0 vs. 77.6). Marked improvement was observed for all angular measurements. No relation was found between the AOFAS, changes in angular measurements, and pre-and postoperative plantar pressure analysis results. SF-36 results improved postoperatively in both groups. Triple arthrodesis decreased the use of orthotics postoperatively in both groups. Previous treatments were not found to affect the end results in this series. CONCLUSIONS: Triple arthrodesis operation is a surgical option with limited alternatives in patients with disabilities originating from feet. Both neurogenic and nonneurogenic patient groups improved significantly, and we were unable to show any significant differences in the results of these two groups.

A lasting solution is hard to achieve in primary hydatid disease of the spine: long-term results and an overview.

STUDY DESIGN: Retrospective evaluation of patients with primary hydatid disease was done, with an overview of the pertinent literature. OBJECTIVES.: To determine the results of surgical decompression and antihelminthic treatment. SUMMARY OF BACKGROUND DATA: Bone involvement in hydatid disease has been reported to be only 0.5 to 4%. Spinal involvement is found in 50% of these cases, with mortality over 50%. Paraplegia is the most serious complication of the disease, caused by compression of the spinal cord by the cysts. Aggressive surgery combined with antihelminthic therapy is recommended to eradicate the disease and prevent recurrence. METHODS: Three patients with primary spinal hydatid disease were operated on several times for multiple recurrences. Combined chemotherapy with either mebendazole or albendazole was also given. The mean age was 52 years, and the mean follow-up time was 92 months. RESULTS: Surgery and chemotherapy improved the symptoms in all cases but could not prevent recurrences and multiple operations. CONCLUSIONS: Primary spinal echinococcosis must be considered in the preoperative differential diagnosis of the atypical presentation of vertebral lesions, especially in patients with risk factors. Early diagnosis and preferably anterior radical surgery combined with antihelminthic therapy of sufficient duration are mandatory to at least halt the progression of symptoms, but these measures could not provide a lasting solution for the patients described here.

Arteriovenous fistula and bone healing: experimental study in the rat.

The incidence of fractures is greater in patients with hemodialysis than in the general population. Surgically created arteriovenous fistulas are widely used in end-stage renal failure patients for the vascular access of hemodialysis. Despite occurrence of fracture at the fistula site in the forearm, bone mineral density is similar in both arms. The effects of arteriovenous fistulas on fracture healing have not been widely studied. The goal of this study was to test the hypothesis that a fracture distal to a surgically-created arteriovenous fistula has negative effects in a rat osteotomy model. The tibial bones were fractured in a monocortical fashion bilaterally. No fixation method was used. The right side was used as control. On the left side of the rat, a side-to-side arteriovenous anastomosis was done between the common femoral vessels proximal to the fracture line under magnification with the operating microscope. Three weeks later, bone segments, including the monocortical osteotomy line, were removed and examined histopathologically. Although the gross appearance of callus formation was not different in both groups, histopathologically, there were more dead medullary bone and less cartilage cells around the osteotomy line in the bone associated with the arteriovenous fistula. But with short-term evaluation of the fracture sites after opening an arteriovenous connection proximal to the fracture site, no real difference was noted related to fracture healing.

[A comparison of different fixation combinations for the treatment of ipsilateral hip and femoral diaphyseal fractures]. / Ayni taraf kalça ve femur cisim kiriklarinin tedavisinde kullanilan farkli tespit kombinasyonlarinin karsilastirilmasi.

BACKGROUND: The effects of four different fixation combinations were retrospectively evaluated on the treatment results of ipsilateral hip and femur fractures. METHODS: Ipsilateral hip and femur fractures of 19 patients (4 females, 15 males; mean age 26 years; range 18 to 41 years) were treated by four fixation combinations. In two groups, diaphysis fractures were treated by plate and screw fixation, and hip fractures by three cannulated screws (n=5) or dynamic hip screws (n=4). In another group, femur fractures were fixed with a retrograde intramedullary locking nail, and hip fractures by three cannulated screws (n=7). Finally, hip and diaphysis fractures in three patients were treated by an antegrade intramedullary locking nail through which a screw was sent to the collum. The mean time to surgery was four days (range 1 to 9 days) and the mean follow-up period was 22.5 months (range 12 to 33 months). RESULTS: All femoral diaphyseal fractures healed in a mean of 3.5 months (range 2.5 to 8 months). No significant differences were found with respect to localization of fractures and amount of displacement, time to healing for hip fractures, the length of hospital stay, and complications. Compared to the other groups, fixation with a retrograde intramedullary locking nail resulted in significantly less healing period (p=0.034), operation time (p<0.001), and blood transfusion during surgery (p=0.025). No patients exhibited decreased range of motion of the hip or implant failure. CONCLUSION: The use of a retrograde intramedullary locking nail with percutaneous screw fixation seems to be more advantageous in the treatment of ipsilateral hip and diaphyseal femoral fractures.