Preliminary Results of Calcaneal Lengthening Osteotomy Combined With Extra-articular Subtalar Arthrodesis for Severe Pes Planovalgus Deformity in Children With Cerebral Palsy: A New Surgical Technique

OBJECTIVE

Pes planovalgus is the most common foot deformity seen in patients with cerebral palsy (CP). There are several different treatment modalities to treat this condition. Single or double calcaneal osteotomies, extra-articular arthrodesis, calcaneo-cuboido-cuneiform osteotomy, intraarticular arthrodesis, and arthroereisis are some of these modalities. Currently, there is insufficient information to determine the most effective treatment approach for pes planovalgus in children with CP. The aim of this study is to show the short to mid-term results of the new technique which combines calcaneus lengthening osteotomy, extra-articular subtalar arthrodesis, and soft tissue reconstruction that aims to decrease recurrence and complication rates of pes planovalgus surgery for patients with ambulatory CP.

METHODS

Patients with CP who were treated with calcaneal lengthening surgery and extra-articular subtalar arthrodesis between 2018 and 2021 were investigated retrospectively. All patients were ambulatory and Gross Motor Function Classification System I-II-III. Functional levels of the patients were assessed with the American Orthopaedic Foot and Ankle Society, Ankle-Hindfoot Score, and the Foot and Ankle Ability Score (Foot and Ankle Ability Measure) in preoperative and postoperative periods. On anteroposterior x-rays, talus-first metatarsal, talocalcaneal, talonavicular coverage angle and on lateral x-rays talus-first metatarsal, talocalcaneal, calcaneal inclination angle and talar tilt angle were evaluated.

RESULTS

The mean follow-up was 46 (range: 36 to 60) months. The mean American Orthopaedic Foot and Ankle Society increased from 41 (20 to 79) to 74 (38 to 93; P < 0.001). The mean Foot and Ankle Ability Measure increased significantly from 35 (7 to 73) to 54 (29 to 96; P<0.001). Clinical results were "satisfactory" for 32 feet, while they were "unsatisfactory" for 2 feet. Significant deformity correction was observed in all radiologic parameters.

CONCLUSION

Our technique is found to be efficient for patients with Gross Motor Function Classification System I-II-III CP with pes planovalgus deformity. In short to mid-term follow-up, the technique achieved successful clinical and radiologic results with low complication rates. Superiority of this technique compared with the traditional ones can only be shown with randomized prospective studies.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

A new configuration of lateral-pin fixation for pediatric supracondylar humeral fracture: A biomechanical analysis

OBJECTIVE

The aim of this study was to biomechanically compare a new lateral-pinning technique, in which pins engage the medial and lateral columns of the distal humerus in a divergent configuration in both the axial and sagittal planes instead of the coronal plane, with the cross-pin, and with 2 and 3 coronally divergent lateral-pin techniques in a synthetic humerus model of supracondylar humerus fractures.

METHODS

Thirty-six identical synthetic models of the humerus simulating a standardized supracondylar humerus fracture were included in this study. They were divided into 4 groups based on the pin configuration of fixation: the new 3-lateral pin-fixation technique (group A), 2 crossed pins (group B), 3 divergent lateral pins (group C), and 2 divergent lateral pins (group D). Each model was subjected to combined axial and torsional loading, and then torsional stability and torsional stiffness (Nmm/°) were recorded.

RESULTS

Group A had greater rotational stability than groups C and D but had no statistically significant additional rotational stability compared with group B (P=.042, P=.008, P=.648, respectively), whereas group B had greater rotational stability than only group D (P=.020). Furthermore, group A demonstrated higher internal rotational stiffness compared with groups C and D (P=.038, P=.006, respectively). Group B had better internal rotational stiffness than group D (P=.015). There was no significant difference in internal rotational stiffness between groups A and B (P=. 542), groups B and C (P=.804), and groups D and C (P=.352). Although no statistically significant differences existed between groups A and B, the modified pin configuration exhibited the highest torsional stability and stiffness. Group D showed the lowest values in all biomechanical properties.

CONCLUSION

This study has shown us that this new lateral-pinning technique may provide torsional resistance to internal rotational displacement as strong as the standard technique of crossed-pin configuration of fixation. Furthermore, with this new pin configuration, greater torsional resistance can be obtained than with either the standard 2- or the standard 3-lateral divergent pin configuration. Cite this article as: Bilgili F, Demirel M, Birişik F, Balcı Hİ, Sunbuloglu E, Bozdag E. A new configuration of lateral-pin fixation for pediatric supracondylar humeral fracture: A biomechanical analysis. Acta Orthop Traumatol Turc., 2023 10.5152/j.aott.2024.21091 [Epub Ahead of Print].

CNT incorporation improves the resolution and stability of porous 3D printed PLGA/HA/CNT scaffolds for bone regeneration

In this study, 3D printed porous poly(lactide-co-glycolide) (PLGA) and its nanocomposites with 5 wt. % hydroxyapatite (HA) and 0.5, 1 and 2 wt. % carboxyl-functionalized multi-walled carbon nanotube (CNT) scaffolds were fabricated by using extrusion-based printing. The printing parameters were optimized by rheological studies. The rheological studies demonstrated shear thinning properties for all compositions and an increase in storage modulus was observed after the addition of CNT. Porous PLGA/HA/CNT scaffolds were printed by applying a pressure of 4.76 bar at 125 °C. The addition of 0.5 wt. % of CNT reduced the strut size and increased the porosity from 42% to 60%. The increase in storage modulus and decrease in strut size were related to hydrogen bonding between CNT, HA and PLGA which ultimately improved shape fidelity. The scaffolds were characterized by analysis of their chemical structure, water contact angle measurement,in vitrobioactivity test, biodegradation test, mechanical analysis, andin vitrocell studies. The scaffolds were found to be more hydrophilic by the incorporation of CNTs. Also, degradation studies showed that the microstructure of the scaffold became more stable with the addition of HA and CNT. The compressive modulus of PLGA/HA/CNT2 scaffold was found to be 548.5 MPa, which is found suitable to replace cancellous bone. The scaffolds were found to be highly biocompatible which is possibly due to alignment of CNT and PLGA during 3D printing process. Alizarin red staining indicated improvement of mineralization of MC3T3-E1 cells on the CNT incorporated porous 3D scaffolds. The results suggest that the produced porous 3D printed PLGA/HA/CNT scaffolds are promising for bone regeneration applications.

An AI based classifier model for lateral pillar classification of Legg-Calve-Perthes

We intended to compare the doctors with a convolutional neural network (CNN) that we had trained using our own unique method for the Lateral Pillar Classification (LPC) of Legg-Calve-Perthes Disease (LCPD). Thousands of training data sets are frequently required for artificial intelligence (AI) applications in medicine. Since we did not have enough real patient radiographs to train a CNN, we devised a novel method to obtain them. We trained the CNN model with the data we created by modifying the normal hip radiographs. No real patient radiographs were ever used during the training phase. We tested the CNN model on 81 hips with LCPD. Firstly, we detected the interobserver reliability of the whole system and then the reliability of CNN alone. Second, the consensus list was used to compare the results of 11 doctors and the CNN model. Percentage agreement and interobserver analysis revealed that CNN had good reliability (ICC = 0.868). CNN has achieved a 76.54% classification performance and outperformed 9 out of 11 doctors. The CNN, which we trained with the aforementioned method, can now provide better results than doctors. In the future, as training data evolves and improves, we anticipate that AI will perform significantly better than physicians.

Acute monoarthritis in children: clinical and laboratory factors distinguishing septic arthritis from noninfectious inflammatory arthritis

OBJECTIVE

Distinguishing septic arthritis from specific inflammatory arthritis in children with acute monoarthritis can be a clinical challenge. This study aimed to assess the diagnostic performance of presenting clinical and laboratory findings for distinguishing septic arthritis from common forms of noninfectious inflammatory arthritis in children with acute monoarthritis.

PATIENTS AND METHODS

Children presented for the first episode of monoarthritis were retrospectively reviewed and then divided into two groups: (1) the septic group, 57 children with true septic arthritis, and (2) the non-septic group, 60 children with several types of noninfectious inflammatory arthritis. Several clinical findings and serum inflammatory markers on admission were documented.

RESULTS

Univariate analyses demonstrated that body temperature, weight-bearing status, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell count (WCC), absolute neutrophil count (ANC), and neutrophil percentage (NP) levels were significantly higher in the septic group than in the non-septic group (p<0.001 for each variable). Based on the ROC analysis, optimum diagnostic cut-off values were 63 mg/L for CRP, 6,300/mm3 for ANC, 53 mm/h for ESR, 65% for NP, 37.1°C for body temperature, and 12,100/mm3 for WCC. While children with no presenting factor had a 4.3% risk of having septic arthritis, those with six predictors had a risk of 96.2%.

CONCLUSIONS

A CRP level of ≥63 mg/L is the best independent predictor of septic arthritis among the commonly used serum inflammatory markers (ESR, WCC, ANP, NP). It should be borne in mind that a child with zero predictors may still have a 4.3% risk of septic arthritis. Thus, clinical assessment is still imperative in managing children presenting with acute mono-arthritis.

Relationship Between Recurrent Adductus Deformity of the Forefoot and Achilles Tendon Elongation Following Ponseti Treatment in Children with Idiopathic Clubfoot

BACKGROUND

Many authors have highlighted the role of muscle strength imbalance around the ankle in the development of recurrent clubfoot following Ponseti treatment. However, this possible underlying mechanism behind recurrence has not been investigated sufficiently to date. This study aimed to explore whether there is a relationship between Achilles tendon elongation and recurrent metatarsus adductus deformity in children with unilateral clubfeet treated by the Ponseti method.

METHODS

A retrospective chart review was performed on 20 children (14 boys and six girls; mean age, 7 years; age range, 5-9 years) with a recurrent metatarsus adductus deformity treated by the Ponseti method for unilateral idiopathic clubfoot. At the final follow-up, isometric muscle strength was measured using a portable, hand-held dynamometer in reciprocal muscle groups of the ankle. The length of the tendons around the ankle was measured ultrasonographically.

RESULTS

The plantarflexion-to-dorsiflexion ratio was lower on the involved side (P = .001). No significant differences in the strength ratio of inversion to eversion were found (P = .4). No difference was observed in lengths of tibialis anterior and posterior tendons (P = .1), but the Achilles tendon was longer on the involved side (P = .001; P < .01). A significant negative correlation was discovered between involved-to-uninvolved Achilles tendon length ratios and involved-to-uninvolved plantarflexion strength ratios (r = -0.524; P = .02) Conclusions: Achilles tendon elongation may be a contributor to the muscle imbalance in clubfeet with relapsed forefoot adduction treated by the Ponseti technique.

Evaluation of a novel semicircular locking external fixator for treating fractures of long bones: Biomechanical comparison with a circular external fixator

PURPOSE

This study aimed to investigate the biomechanical properties of a novel semicircular locking external fixator with locking screw mechanism, shape of trapezoidal corrugations, half- ring designed for greater stability.

MATERIALS AND METHODS

The novel external fixator had a half-ring with the shape of trapezoidal corrugations and locking screws fixing the bone at different angles in all three planes (sagittal, axial, and coronal). The biomechanical properties of the semicircular locking external fixator (group 1) were compared with those of a standard Ilizarov-type circular external fixator (group 2) (TST, İstanbul, Turkey) in an experimental study design. Five frames were used in each group. Standard PE 1000 (polyethylene) rod models (n = 10) simulating the tibia bone model were used. Both systems were compared biomechanically by applying axial and torsional loads simultaneously.

RESULT

Two samples in group 2 were damaged before the test ended during axial loading. All of the samples in group 1 completed the tests without damage after 150,000 cycles. The axial stiffness of the semicircular locking external fixator was found to be significantly higher than that of the Ilizarov-type circular external fixator (p < 0.05). No statistically significant difference was found between the two fixators in torsional loading. The application time of semicircular locking external fixator was significantly shorter than Ilizarov-type circular external fixator (p < 0.05).

CONCLUSION

The novel semicircular locking external fixator was biomechanically stronger than the Ilizarov-type external fixator for treating fractures of long bones. It can be used as a permanent external fixator for the definitive treatment of long bone fractures with soft tissue damage in terms of stability and application time.

Vitamin D level, body mass index and fracture risk in children: vitamin D deficiency and fracture risk

The objective of this study was to determine the impacts of preventable causes of fracture, such as vitamin D deficiency, disturbed calcium homeostasis and obesity on fracture occurrence in minor traumas. In this way, the effects of relevant parameters on fracture may be further elucidated. A prospective case-control study in children aged 2-18 years children with and without fractures was performed. Participants with a pediatric trauma score higher than 10 presenting to minor trauma were included to exclude the significant impact of severe trauma on fracture. The effects of obesity, parameters associated with vitamin D and Ca homeostasis on fracture occurrence were evaluated. Univariate and multivariate analyses were used to test for associations between fracture status and the assessed variables. The relationships between the variables and the odds of fracture occurrence were examined using logistic regression models. The sample consisted of 76 patients and 50 controls. There were no significant differences between the patients and controls in terms of age, sex, trauma type and pubertal period. The patients had a significantly higher mean BMI percentile (61.2 ± 30.7, 36.7 ± 30.7; P < 0.001). Likewise, patients were more likely than controls to have a lower mean 25(OH)D level and mean phosphorus level (respectively, 13.4 ± 7.0, 17.3 ± 7.8; P = 0.004, and 4.6 ± 0.7, 5.1 ± 0.8; P < 0.001). Moreover, fractures were substantially more frequent in children with vitamin D deficiency (<20 ng/mL, χ2: 7.781, df: 1, P = 0.005). In the multivariate logistic model, BMI percentile and vitamin D levels remained significantly associated with increased odds of fracture [1.02 (1.01-1.04), P < 0.001 and 0.93 (0.89-0.98), P = 0.01]. The present study supports an association of high BMI and vitamin D deficiency with an increased odds of fracture occurrence in children. The findings may help physicians to reduce the risk factors of fracture by preventive efforts. Thus, unexpected health costs and morbidity may be minimized.

Temporary Epiphysiodesis Using the Eight-Plate in the Management of Children with Leg Length Discrepancy: A Retrospective Case Series

BACKGROUND

Although eight-plates have been shown to be effective in correcting angular deformities of the knee, the literature is scarce regarding the efficiency of this method in treatment of children with LLD.

OBJECTIVES

The aim of this study was to determine the efficiency, rates of correction and complications of epiphysiodesis using eight-plate in the management of children with leg length discrepancy (LLD).

METHODS

Eleven consecutive patients with LLD (7 boys, median age = 9, age range 6-11 years) who were treated by temporary epiphysiodesis using eight-plates were retrospectively reviewed and included in the study. The main indication for temporary epiphysiodesis was an LLD between 2 and 5 cm in all patients. LLD and lower limb alignment were examined on lower extremity weight-bearing radiography preoperatively and at skeletal maturity. Longitudinal correction rate was calculated. The final LLD was categorized as ''good result'' (final LLD < 1.5 cm), ''fair result'' (1.5-2 cm), and ''poor result'' (> 2 cm).

RESULTS

The mean treatment period with the eight-plate was 44 (min to max = 32-72) months, and the mean follow-up from the index surgery to the final follow-up was 62 (min to max = 39-106) months. The mean LLD was significantly reduced from 39 (range 25-50) mm preoperatively to 22.40 (range 6-55) mm postoperatively (p = 0.006). The mean longitudinal correction rate was found to be 0.48 mm/mo. Radiographic evidence of lower limb deformity in frontal and sagittal planes was determined in neither preoperative nor postoperative deformity analysis. No major complications were recorded.

CONCLUSION

For the management of children with LLD of 2-5 cm, temporary hemiepiphysiodesis using the eight-plate seems to be an effective treatment with low complication rates.

Effects of Collagen- and Arginine-Fortified Osteokine Supplementation on Fracture Healing

Introduction

Delayed union or nonunion is an important clinical challenge for orthopedic surgeons. In addition to the main treatment algorithms, the use of nutritional supplements is increasingly common. In this study, we investigated the effects of nutritional supplements fortified with arginine and collagen on fracture healing.

Materials and methods

Twenty-four rats with femur fractures were divided into experimental and control groups. Intramedullary fixation was performed in both groups. 20 ml/kg nutritional supplement was given to the experimental group. Radiological examination was performed at third and sixth weeks, and histopathological examination was performed at the sixth week.

Results

No statistically significant difference was found between the radiological scores of the groups at the third and sixth weeks. Nutritional supplement affected the histological properties of callus. Histological evidence of bone healing was observed by the sixth week in both groups but the score was higher in nutritional supplement group. A statistically significant difference was found between the histopathological scores of the groups at the sixth week.

Conclusion

Arginine- and type two collagen-augmented traditional nutritional supplements may help to achieve more successful results in fracture healing.

Determining the relationship between the impairment of selective voluntary motor control and gait deviations in children with cerebral palsy using simple video-based analyses

BACKGROUND

The impairment of selective voluntary motor control (SVMC) in children with cerebral palsy (CP) has been shown to correlate with their gait characteristics using complex 3D gait analysis systems (3DGA); however, this relationship has not been investigated using simple video-based observational gait analysis (VBOGA). The aim of this study was to determine the relationship between VBOGA and SVMC of the lower extremities in children with CP.

METHODS

Forty-two CP children 10.9 ± 5.7 years old with Gross Motor Function Classification System (GMFCS) levels I-III participated in the study. Their gait characteristics were assessed using the Edinburgh Visual Gait Score (EVGS), and selective voluntary motor control was tested using the Selective Control Assessment of the Lower Extremity (SCALE). Spearman's rho correlation test with Cohen's classification were used in the statistical analyses.

RESULTS

The GMFCS levels (r = 0.604, p < 0.001), foot clearance (r = -0.584. p < 0.001), and maximum ankle dorsiflexion (r =-0.567, p < 0.001) during the swing phase had strong correlations with total SCALE scores. There was also a moderate correlation between total SCALE scores and total EVGS (r =-0.494, p < 0.001), knee extension in the terminal swing phase (r = -0.353, p < 0.001), peak sagittal trunk position (r = -0.316, p < 0.005), and maximum lateral shift (r = -0.37, p < 0.001).

CONCLUSION

Impaired lower extremity SVMC was noticeably related to the foot and ankle movements in the swing phase and initial stance during walking as well as the total EVGS scores and sagittal and frontal trunk movements. The SCALE correlations with VBOGA were similar those observed in the complex 3DGA in the literature; therefore, we suggest that SVMC impairment of gait could be evaluated using simple VBOGA. These findings may help to tailor physical therapy programs for CP children to increase their motor control and walking quality.

Which inflammatory marker is more reliable in diagnosing acute septic arthritis in the pediatric population?

BACKGROUND

The present study aimed to investigate diagnostic values of C-reactive protein (CRP), white blood cell (WBC), erythrocyte sedimentation rate (ESR), neutrophil to lymphocyte ratio (NLR), and the platelet to lymphocyte ratio as possible indirect inflammatory markers in children with septic arthritis (SA) for diagnosis process.

METHODS

The medical records of pediatric patients with SA who underwent debridement surgery between February 2005 and November 2018 were obtained from the hospital records. A total of 59 children with SA and 60 age- and gender-matched healthy controls were enrolled in the study. Hemograms parameters including WBC count, neutrophil count, lymphocyte count, hemoglobin, platelet count, CRP, ESR, NLR, and platelet to lymphocyte ratio. Biochemical parameters including alanine transaminase, aspartate aminotransferase, blood urea nitrogen, creatinine, glucose, and albumin were investigated and compared between both groups.

RESULTS

Fifty-nine patients, 30% female (n: 18) and 70% male (n: 41), who had received operations for SA were included in the study. The mean age of the patients was 7.1 (range 6 days to 15 years) years and mean follow up 56.6 (12-140) months. No significant differences were observed in any biochemical parameters between the groups. However, a significant difference was found between the septic arthritis and the control group in all hemogram parameters.

CONCLUSIONS

Although the sensitivity and specificity of the NLR are lower than CRP, ESR, and WBC which are most commonly used inflammatory parameters in diagnosis process of septic arthritis, NLR may be useful in confirming the diagnosis in the clinical practise, with an optimum diagnostic cut-off value of 4.05.

The Relationship of One Leg Standing Duration to GMFM Scores and to Stance Phase of Walking in Children with Hemiplegic Cerebral Palsy

Background: Lack of stability during stance negatively impacts gait and motor function for children with unilateral cerebral palsy. Improving stability and balance are the focus for gait rehabilitation). The One-Leg-Standing-Test may give valuable information about motor function and stability of stance for patients with unilateral cerebral palsy.Objective: This study aimed to investigate the relationship between the One-Leg-Standing-Test and the gross-motor-function-measurement and single-limb support time.Methods: The study included 18 patients with unilateral cerebral palsy (age 11.08 [SD 2.84] years old). The One-Leg-Standing-Test and pedobarographic evaluation were performed. Sections D and E of the gross-motor-function-measurement were assessed, and in pedobarographic evaluation, the single-limb support time (the total duration of mid-stance and terminal-stance during walking) was calculated to describe stability during stance.Results: For patients, the One-Leg-Standing-Test scores and single-limb support time values were lower on the affected side than on the unaffected side. The One-Leg-Standing-Test was correlated with single-limb support time (p = .02, r = 0.60) and section E (p < .01, r = 0.59) values. The One-Leg-Standing-Test was also correlated to total stance phase and section D.Conclusion: The One-Leg-Standing-Test gives valuable information about gross-motor-function but cannot be substituted for motor function tests. The single-limb support time value may be used to describe stability in stance during walking.

A novel approach for computerized quantitative image analysis of proximal femur bone shape deformities based on the hip joint symmetry

As a result of most of the bone disorders seen in hip joints, shape deformities occur in the structural form of the hip joint components. Image-based quantitative analysis and assessment of these deformities in bone shapes are very important for the evaluation, treatment, and prognosis of the various hip joint bone disorders. In this article, a novel approach for the image-based computerized quantitative analysis of proximal femur shape deformities is presented. In the proposed approach, shape deformities of the pathological proximal femurs were quantified over the contralateral healthy proximal femur shape structure of the same patient in 2D by taking the hip joint symmetry property of human anatomy into consideration. It is based on the idea that if the right and left proximal femurs in bilateral hip joints are highly symmetrical and also if one of the proximal femurs is healthy and the contralateral one is pathological, the non-overlapping bone shape regions can represent the deformities in pathological proximal femurs when both proximal femurs are registered to overlap each other. In the methodological process of the proposed study, a set of image preprocessing operations was primarily performed on the raw magnetic resonance imaging (MRI) data. Then, the segmented proximal femurs in bilateral hip joint images were automatically aligned with the Iterative Closest Point (ICP) rigid registration method. Following the registration, a set of image postprocessing operations was performed on the images of proximal femurs aligned. In the quantification phase, the bone shape deformities in pathological proximal femurs were quantified simply in terms of the mismatching area in 2D by measuring a shape variation index representing the total bone shape deformity ratio. To evaluate the proposed quantitative shape analysis approach, bilateral hip joints in a total of 13 coronal MRI sections of 13 patients with Legg-Calve-Perthes disease (LCPD) were used. Experimental studies have shown that the proposed approach has quite promising results in the quantitative representation of the pathological proximal femur shape deformities. Furthermore, consistent results have been observed for the Waldenström classification stages of the disease. The shape deformity ratios in pathological proximal femurs were quantified as 9.44% (±1.40), 18.38% (±6.30), 24.73% (±12.42), and 27.66% (±10.41), respectively for the Initial, Fragmentation, Reossification, and Remodelling stages of LCPD with the quantification error rates of 0.29% (±0.16), 0.58% (±0.71), 1.12% (±0.82), and 0.80% (±0.98). Additionally, a mean error rate of 0.65% (±0.68) was observed for the quantified shape deformity ratios of all samples.

Mid-term results of hindfoot arthrodesis with a retrograde intra-medullary nail in 24 patients with diabetic Charcot neuroarthropathy

Background and purpose - Hindfoot arthrodesis using retrograde intramedullary nailing assumes a critical role in limb salvage for patients with diabetic Charcot neuro-arthropathy (CN). However, this procedure is compelling and fraught with complications in diabetic patients. We report the mid-term clinical and radiological outcomes of retrograde intramedullary nailing for severe foot and ankle deformity in patients with diabetic CN.Patients and methods - Hindfoot arthrodesis was performed using a retrograde intramedullary nail in 24 patients (15 females) with diabetic Charcot foot. The mean age of the patients was 62 years (33-82); the mean follow-up was 45 months (24-70). The primary outcomes were rates of fusion, limb salvage, and complications.Results - The overall fusion rate was 23/24, and none of the patients needed amputation. The rate of superficial wound infection was 4/24, and no deep infection or osteomyelitis was observed postoperatively.Interpretation - For selected cases of diabetic CN with severe foot and ankle deformity, hindfoot arthrodesis using a retrograde intramedullary nail seems to be a good technique in achieving fusion, limb salvage, and avoidance of complications.

Intraoperative testing of passive and active state mechanics of spastic semitendinosus in conditions involving intermuscular mechanical interactions and gait relevant joint positions

In cerebral palsy (CP) patients suffering pathological knee joint motion, spastic muscle's passive state forces have not been quantified intraoperatively. Besides, assessment of spastic muscle's active state forces in conditions involving intermuscular mechanical interactions and gait relevant joint positions is lacking. Therefore, the source of flexor forces limiting joint motion remains unclear. The aim was to test the following hypotheses: (i) in both passive and active states, spastic semitendinosus (ST) per se shows its highest forces within gait relevant knee angle (KA) range and (ii) due to intermuscular mechanical interactions, the active state forces elevate. Isometric forces (seven children with CP, GMFCS-II) were measured during surgery over a range of KA from flexion to full extension, at hip angle (HA) = 45° and 20°, in four conditions: (I) passive state, (II) individual stimulation of the ST, simultaneous stimulation of the ST (III) with its synergists, and (IV) also with an antagonist. Gait analyses: intraoperative data for KA = 17-61° (HA = 45°) and KA = 0-33° (HA = 20°) represent the loading response and terminal swing, and mid/terminal stance phases of gait, respectively. Intraoperative tests: Passive forces maximally approximated half of peak force in condition II (HA = 45°). Added muscle activations did increase muscle forces significantly (HA = 45°: on average by 42.0% and 72.5%; HA = 20°: maximally by 131.8% and 123.7%, respectively in conditions III and IV, p < 0.01). In conclusion, intermuscular mechanical interactions yield elevated active state forces, which are well above passive state forces. This indicates that intermuscular mechanical interactions may be a source of high flexor forces in CP.

Intraoperative experiments combined with gait analyses indicate that active state rather than passive dominates the spastic gracilis muscle's joint movement limiting effect in cerebral palsy

BACKGROUND

In cerebral palsy, spastic muscle's passive forces are considered to be high but have not been assessed directly. Although activated spastic muscle's force-joint angle relations were studied, this was independent of gait relevant joint positions. The aim was to test the following hypotheses intraoperatively: (i) spastic gracilis passive forces are high even in flexed knee positions, (ii) its active state forces attain high amplitudes within the gait relevant knee angle range, and (iii) increase with added activations of other muscles.

METHODS

Isometric forces (seven children with cerebral palsy, gross motor function classification score = II) were measured during surgery from knee flexion to full extension, at hip angles of 45° and 20° and in four conditions: (I) passive state, after gracilis was stimulated (II) alone, (III) simultaneously with its synergists, and (IV) also with an antagonist.

FINDINGS

Directly measured peak passive force of spastic gracilis was only a certain fraction of the peak active state forces (maximally 26%) measured in condition II. Conditions III and IV caused gracilis forces to increase (for hip angle = 45°, by 32.8% and 71.9%, and for hip angle = 20°, by 24.5% and 45.1%, respectively). Gait analyses indicated that intraoperative data for knee angles 61-17° and 33-0° (for hip angles 45° and 20°, respectively) are particularly relevant, where active state force approximates its peak values.

INTERPRETATION

Active state muscular mechanics, rather than passive, of spastic gracilis present a capacity to limit joint movement. The findings can be highly relevant for diagnosis and orthopaedic surgery in individuals with cerebral palsy.

A new scheme for automatic 2D detection of spheric and aspheric femoral heads: A case study on coronal MR images of bilateral hip joints of patients with Legg-Calve-Perthes disease

BACKGROUND AND OBJECTIVE

In orthopaedics, hip joint and circular structure of the femoral head can be distorted by a wide variety of hip joint disorders. Hence, automatic detection and segmentation of the femoral head is an important issue in the studies of computerized hip joint segmentation, quantification and assessment. In the proposed study, we need to detect the center coordinates and radius of spheric and aspheric femoral heads automatically in bilateral hip magnetic resonance (MR) images using a new scheme.

METHODS

This paper presents a new two-level scheme based on the Circular Hough Transform (CHT) and Integro-differential Operator (IDO) to detect the spheric and aspheric femoral heads in MR images in 2D. Initially, MR slices are divided vertically into two equal halves to automatically separate the hip joints and Canny's edge detection method is performed on each of the halves to obtain edge images. Then, healthy and pathological femoral heads are detected by performing the CHT over edge images in the first stage of proposed scheme. In the second stage, femoral head circle detected with CHT is fine tuned by performing Daugman's IDO.

RESULTS

Performance evaluations of the proposed femoral head detection scheme were carried out on healthy and pathological hip joints in 24 coronal MR image sections belong to 13 patients with Legg-Calve-Perthes Disease (LCPD). In performance evaluations on 24 healthy and 24 pathological hip joints, Root Mean Square Error (RMSE) and Dice Similarity Coefficient (DSC) values were measured for automatically detected femoral heads. We observed 1.96 mm. (std. 1.21 mm.) mean RMSE for center coordinates, 1.45 mm. (std. 1.39 mm) mean RMSE for radii, 0.8978 (std. 0.0733) mean DSC on healthy femoral heads and 3.56 mm. (std. 3.19 mm.) mean RMSE for center coordinates, 1.56 mm. (std. 1.33 mm.) mean RMSE for radii, 0.8529 (std. 0.0927) mean DSC on pathological femoral heads.

CONCLUSIONS

Proposed femoral head detection scheme has promising results for the detection and the segmentation of the spheric and aspheric femoral heads and also has a potential to be used in detection of the other anatomical structures having a circular shape.

Subacute Osteomyelitis of the Fibula due to Corynebacterium striatum in an Immunocompetent Child: A Case Report

CASE

A 4-year-old boy presented with a history of swelling and pain in his ankle for 1 month. X-ray showed a periosteal reaction, and magnetic resonance imaging (MRI) favored radiodense signs in a T2-weighted image. An open biopsy was performed, and cultures grew Corynebacterium spp. Further research showed that the pathogen was Corynebacterium striatum subtype. Vancomycin and cefazolin were given for 6 weeks. Clinical, X-ray, and MRI signs indicated improvement, and there were no complications with 2-year follow-up.

CONCLUSIONS

C. striatum is an unexpected pathogen for subacute osteomyelitis in children. As far as we know, this is the first case report of subacute osteomyelitis in a child with a normal immune system caused by C. striatum.

A case of hypomelanosis of Ito accompanied by unilateral abnormal limb overgrowth and delayed speech

Hypomelanosis of Ito (HI) is characterized by unilateral or bilateral hypopigmented skin lesions and usually presents as a multisystemic disorder. Skin lesions may develop in different textures, such as linear, whorled, or patchy, and are often accompanied by abnormalities of the central nervous system, skeletal system, eyes, and teeth. HI is associated with sporadic gene mutations but not gender. Presentation of the current case may be of use in reminding practitioners of the common extracutaneous findings of HI, along with some rare manifestations, such as delayed speech and asymmetric limb growth.

High Rates of Psychiatric Disorders and Below Normal Mental Capacity Associated With Spastic Peroneal Flatfoot: A New Relationship

Spastic peroneal flatfoot (SPFF) is a rare hindfoot pathology usually seen in the adolescent age group that is characterized by painful spasms in the peroneal muscles. We have clinically observed that patients with SPFF also have some behavioral and emotional difficulties and problems in their academic achievements. Because of these observations, we investigated the prevalence and patterns of psychiatric disorders and intellectual disability among young subjects with SPFF. Our cohort consisted of 16 patients with SPFF. Their mean age at presentation was 21 (range 13 to 31) years. Only 6 patients had a tarsal coalition as an underlying condition. The psychometric evaluation was conducted using validated instruments (Wechsler Intelligence Scale for Children-revised form, Stanford Binet intelligence quotient [IQ] test, and Cattell IQ test). Psychiatric disorders were assessed using a semistructured diagnostic instrument (Schedule for Affective Disorders and Schizophrenia for School Age Children Present and Lifetime Version). The testers and psychiatrists were unaware of the orthopedic condition and the preliminary psychiatric diagnoses. The ethical committee approved the study protocol. The mean follow-up period was 41 (range 12 to 97) months. The mean IQ score of the patients was 75.1 ± 17.9 (range 52 to 107). Compared with the general population, the rate of intellectual disability was significantly greater (p = .0001) and the rate of normal intelligence significantly lower (p = .0015) in our patient group. Furthermore, according to the community schooling ratio, our cohort also had lower junior high and secondary education rates compared with the general population. The rate of most psychiatric disorders diagnosed in the SPFF patients was greater than that in the normal population. The most commonly identified psychiatric disorders were social phobia and attention deficit and hyperactivity disorder (75%). Timely interventions of the psychosocial and academic problems of patients with SPFF might increase their compliance with orthopedic treatment and help with their psychological well-being and academic achievement. In addition, this relationship might be a clue for uncovering the etiology of this disease, which has not yet been clarified.

Treatment of Graf Type IIa Hip Dysplasia: A Cut-off Value for Decision Making

Background:

The rate of spontaneous normalization in type IIa hips is reported to be high, whereas dysplsia persists or worsens in 5%-10% of cases.

Aims:

To evaluate the natural course of type IIa hips using Graf’s own perspective of physiological immaturity and maturational deficit.

Study Design:

A single center, retrospective cohort study.

Methods:

This was an institutional review board-approved retrospective review of all patients diagnosed with type IIa hip dysplasia at a single institution from 2012 to 2014. All patients included in the study had hip ultrasonography at about 6 weeks and 3 months of age. To assess reliability in α and β angles, ultrasonography measurements were carried out on the same image individually by all observers. The α and β angles were used as the main outcome measurements to evaluate hip maturation at the last follow-up. A receiver operating characteristics curve was drawn at the 3 month ultrasonography to evaluate the cut-off values for α and β angles for persistent dysplasia.

Results:

Sixty-four patients and 88 affected hips (63% unilateral and 37% bilateral) were included. The mean age at diagnosis was 6.4±2.7 weeks. Fifty-four hips were type IIa(+) (physiologically immature) and 34 hips were type IIa(-) (maturational deficit) at the initial ultrasonography evaluation. Improvement to type I was seen in 52 type IIa(+) and 17 type IIa(-) hips. Receiver operating characteristic analyses showed that patients do well if the α angle was >55° (area under the curve: 0.86; p<0.001 for the left hip and area under the curve: 0.72; p=0.008 for the right hip).

Conclusion:

The cut-off α angle value of 55° on initial ultrasonography should be considered to prevent future dysplasia. An α angle <55° on the initial ultrasonography was an independent predictor of worsening sonographic findings.

An analysis of variables affecting the duration of Pavlik harness treatment: Is it possible to predict the duration of treatment?

BACKGROUND

Pavlik harness is the initial treatment for the infants with developmental dysplasia of the hip who have not yet begun walking.

OBJECTIVES

The present study evaluates the variables which affect the duration of PH treatment for patients successfully treated.

STUDY DESIGN

Cross-sectional study.

METHODS

Pavlik harness was employed for 140 hips of 87 patients with developmental dysplasia of the hip in our institution between 2010 and 2013. In all, 55 hips of 46 patients who were treated successfully with Pavlik harness were included in this study. According to Graf's sonographic classification, 23 hips were Type IIC, 26 were Type IID, and 6 were Type III. The studied variables were (1) alpha angle, (2) age at the start of treatment, (3) laterality, and (4) gender. The variables were compared with the duration of Pavlik harness treatment.

RESULTS

A highly significant inverse correlation was observed between Pavlik harness application time and alpha angle at the start of the treatment ( r = -0.050; p < 0.001). Bilateral involvement has statistically longer duration, when compared with unilateral involvement ( r = 0.28; p = 0.036). No statistically significant difference was present between duration of treatment and age at the start of Pavlik harness treatment ( r = -0.034; p = 0.804). There was no statistical significance between gender and duration of Pavlik harness ( r = 0.201; p > 0.05).

CONCLUSION

The duration of treatment was negatively correlated with the initial alpha angle. A change of 1 degree in alpha angle may alter the duration of treatment as 0.89 week calculated by the formula (Application time (Week) = 56.6 - 0.89 × alpha angle). Bilateral involvement may need longer Pavlik harness treatment. Clinical relevance Pavlik harnes generally is the first treatment method for the infants with DDH. This study suggest conclutions about how long time is the Pavlik harness should be kept on the infants? The main indicator is initial alfa angle which is negatively correlated with the duration of treatment.

Fixation of extra-articular distal humeral fractures with a lateral approach and a locked plate: an alternative method

OBJECTIVE

The purpose of this study was to evaluate the efficacy of lateral approach and anterolateral anatomical locked plate fixation on clinical and radiological healing of extra-articular distal humeral fractures.

METHODS

Twenty-three (17 male, 6 female) consecutive patients who underwent surgical management for closed extra-articular comminuted distal humeral fractures between 2006 and 2013 were included in this study. Anterolateral fixation with an anatomical locked plate using a lateral approach was preferred. Mean age was 34 years (range: 17-56 years). AO Foundation/American Orthopaedic Trauma Association (AO/OTA) classification was used; all patients had AO/OTA 12-B1.3 type fractures. Inclusion criteria were patients with polytrauma, late-onset radial nerve injury, and unsatisfactory closed reduction. Patients were followed up at postoperative weeks 6, 12, and 24, and in 3-month intervals thereafter. Mean follow-up period was 16 months (range: 14-18 months). Functional results were evaluated using the Disabilities of the Arm, Shoulder and Hand (DASH) score, visual analog scale (VAS) score, and Mayo elbow performance score.

RESULTS

Mean flexion was 135° (range: 128-140°) at 24 weeks postoperatively; there was no loss of pronation and supination of the forearm. All fractures healed uneventfully in an average of 19.3 weeks (range: 16-24 weeks). Mean Mayo elbow performance score and DASH score at 24 weeks improved from 66.6 (range: 50-85) to 100 and from 53.6 (range: 25.75-80.75) to 12.7 (range: 5-26.5), respectively. VAS score at 24 weeks improved from 4 (range: 3-5) to 0.5 (range: 0-1). Postoperative radial nerve paralysis and infection were not observed.

CONCLUSION

We recommend anterolateral anatomical locked plate fixation using a lateral approach as an alternative method in the management of distal humeral extra-articular fractures. This enables rigid fixation of the distal fragment without interfering and impinging on the olecranon fossa, allows early active range of elbow motion, and avoids iatrogenic triceps muscle injury and radial nerve exposure, which prevents surgical radial nerve injury.

The effects of preoperative non-invasive cardiac tests on delay to surgery and subsequent mortality in elderly patients with hip fracture

OBJECTIVE

To investigate the effects of preoperative cardiac tests on the surgical treatment plan and subsequent effects on mortality in elderly patients with hip fracture.

METHODS

In this retrospective study, 116 patients aged 60 years or above who underwent hip fracture surgery between 2010-2013 were evaluated. Of the patients with similar preoperative clinical risk factors, 20 patients with additional preoperative cardiac tests such as echocardiography or thalium scintigraphy constituted Group 1, whereas 28 patients without additional cardiac tests constituted Group 2. Statistical analyses were performed using the SPSS 21 statistical package software. Normal distribution of the data was determined by the Shapiro-Wilk test and histography. Intergroup and mortality comparisons were performed by Mann-Whitney U, Yates-corrected chi-square and Fisher's exact tests.

RESULTS

The mean time between fracture and operation was 6 days (range, 4-14) in Group 1, and 2 days (range, 0-3) in Group 2. There was a significant difference in time-to-operation between the groups (p< 0.001). The age and gender distribution of both groups were homomgenous (p= 0.64, p= 1.0). Both groups were comparable in terms of fracture type, treatment, and anesthesia (p= 0.36, p= 0.42, p= 1.0). At the end of 1 year, six (30%) patients in Group 1 and three (10.7%) patients in Group 2 were deceased. Both groups were comparable in terms of mortality (p= 0.137). There was a significant difference between the two groups in terms of complications (p< 0.05).

CONCLUSIONS

Unnecessary cardiac tests in elderly patients with hip fracture led to a delay in their surgery, yet did not change their cardiac treatment plan. This delay in obtaining hip fracture surgery increases complication rates, hospitalization duration, and costs.

Factors affecting adherence with foot abduction orthosis following Ponseti method

OBJECTIVE

The Ponseti method is an effective protocol for treatment of congenital idiopathic clubfoot. Foot abduction orthosis (FAO) is sometimes necessary to preserve the correction achieved with the serial casting and tenotomy. Patient and family adherence to brace use is a common problem, as nonadherence is directly related to relapse. The aim of this study was to investigate patient and parent characteristics related to relapse.

METHODS

One hundred and fifty-three children who were treated with Ponseti method (mean age: 44.62 months; range: 16-104 months) and their parents were included in the study. Thirty-one patients experienced relapse at an average follow-up of 32 months (range: 6-84 months) since beginning orthosis use. At the time of follow-up visits, parents were questioned about brace use adherence. Satisfaction with Symptoms Scale in the American Academy of Orthopaedic Surgeons (AAOS) Pediatric Outcomes Data Collection Instrument (PODCI) was used.

RESULTS

Difficulties with brace use were encountered in 122 children. Children of parents who were satisfied with the treatment had relapse at an average of 69.13±2.64 months, and those of parents who were not satisfied at 32.83±7.51 months. The most important variable was the child's adaptation to the orthosis treatment without an adverse reaction. Additionally, better compliance was found in children with higher-educated parents.

CONCLUSION

Non-compliance with periods of intolerance is very common for children during orthosis treatment. Parents' coping strategies are very important to avoid relapses. It is important to develop strategies to guide parents.

Preliminary report on amputation versus reconstruction in treatment of tibial hemimelia

OBJECTIVE

Tibial hemimelia is a rare disorder characterized by the absence or hypoplasia of the tibia with associated rigidity. The aim of this study was to retrospectively evaluate the affectivity of reconstructive surgeries including centralization of the knee-ankle joints and lengthening with Ilizarov principles, as well as physical and functional results of amputation and reconstruction.

METHODS

This is an IRB-approved retrospective review of all patients diagnosed with tibial hemimelia who required surgery at a single institution between 1998 and 2011. Charts were analyzed for clinical and radiographical findings. At final follow-up, patients underwent physical and radiographic examination. Patients and their parents were asked to complete the SF-10™ health survey (QualityMetric Inc., Lincoln, RI, USA).

RESULTS

Twenty-one patients (12 male, 9 female) with 30 affected extremities were included. Mean age was 4.8±3.1 years at initial surgery. Knee level disarticulation was performed in 6 extremities of 4 patients. One patient with type III underwent transtibial amputation. Mean number of surgeries for each patient was 6.4±3.3, and mean duration of external fixator and casting was 17±6 months. Mean lengthening was 4.9±1.3 cm, and mean limb length discrepancy was 3.1±1.7 cm at 5.8±3.7 years at follow-up. SF-10™ scores were similar in disarticulated and reconstructed patients (p=0.63). All scores were significantly higher when disarticulation was performed in cases of knee instability (p<0.01).

CONCLUSION

When stability of the knee joint is present, treatment modality should be chosen according to the existence of the proximal tibia. Amputation should be preferred in cases of knee joint instability.

Reliability of Computer-Assisted and Manual Measurement Methods for Assessment of Graf Type 1 and Type 2 Hip Sonograms

OBJECTIVES

The purpose of this study was to investigate the interobserver, intraobserver, and intermethod reliability of computer-assisted digital and manual measurements of hip sonograms.

METHODS

Seventy-four hip sonograms were evaluated in this retrospective study. Five evaluators measured digital images and manual paper printouts according to the Graf method (Arch Orthop Trauma Surg 1984; 102:248-255). Interobserver and intraobserver reliability rates were calculated. Reliability criteria were graded on a numeric scale.

RESULTS

The interobserver reliability of both computer-based and manual methods for alpha angle measurements was good to excellent, but the interobserver reliability was fair to poor for beta angle measurements. Intraobserver reliability was varied. Alpha angle measurements by both manual and computer-based methods had high concordance with each other, whereas beta angle measurements had low concordance. The intermethod variability did not differ between observers.

CONCLUSIONS

The alpha angle measurements had high concordance with each other for both manual and computer-based methods, whereas the beta angle measurements had low concordance. This information should be taken into account in clinical practice. Overall, the two measurement methods were reliable and consistent with each other.

[Retrospective analysis of AO 42A-B type tibia fractures treated with percutaneus locked plating and intramedullary nailing]

BACKGROUND

In this study, the results of AO 42A and 42B type tibia fractures treated with intramedullary nail (IMN) and percutaneus locking plate (PLP) were evaluated. The complications were examined, and it was questioned whether the type of fixation had an effect on union time and functional results.

METHODS

Forty-two patients with extraarticular distal tibial fractures were enrolled in this retrospective study. Eighteen patients were treated with closed IMN (Group I) and 24 patients were treated with PLP fixation (Group II). Mean age was 41 (range: 16-70) years; thirty-two of the patients were men. Fractures were classified according to the AO classification system. Union time, functional results and complications (malunion, malalignment, infection) were compared. The American Orthopaedic Foot and Ankle Surgery (AOFAS) scoring was used to compare functional results.

RESULTS

The average follow-up period was 20 (12-32) months for Group I and 23 (13-36) months for Group II. The average union time was 16 (12-24) weeks in Group I and 19 (range: 16-24) weeks in Group II (p=0.002). The AOFAS scoring was 85 (range: 69-100) points in Group I and 81 (range: 60-95) points in Group II. The difference in AOFAS scoring was not significant (p=0.06). Two patients had nonunion in Group II. Two patients in Group I and three patients in Group II had malalignment.

DISCUSSION

We suggest that IMN can provide early healing time. Although it is not statistically significant, complication rate was lower and functional results were better in patients treated with IMN.

Arthroscopic excision of acetabular osteoid osteoma in a 7-year-old patient

The purpose of this study was to present the case report of a 7-year-old patient who was treated with hip arthroscopy for an acetabular osteoid osteoma. A 7-year-old patient was referred to our clinic with hip pain. In the assessment of the patient, an acetabular osteoid osteoma was detected in his right hip; it was adjacent to his triradiate cartilage. An arthroscopic surgery was planned as an alternative to open safe hip dislocation. The osteoid osteoma was completely removed with hip arthroscopy. Postoperative CT scanning and histopathological analysis confirmed the diagnosis. Exposure of the acetabulum can be problematic in paediatric patients due to the potential risks of open safe dislocation. Hip arthroscopy can safely be used for benign hip lesions in paediatric patients. Level of evidence Case report, Level V.

Can Normal Fracture Healing Be Achieved When the Implant Is Retained on the Basis of Infection? An Experimental Animal Model

BACKGROUND

Infection after open fractures is a common complication. Treatment options for infections developed after intramedullary nailing surgery remain a topic of controversy. We therefore used a rat fracture model to evaluate the effects of infection on osseous union when the implant was maintained.

QUESTIONS/PURPOSES

In a rat model, (1) does infection alter callus strength; (2) does infection alter the radiographic appearance of callus; and (3) does infection alter the histological properties of callus?

METHODS

An open femoral fracture was created and fixed with an intramedullary Kirschner wire in 72 adult male Sprague-Dawley rats, which were divided into two study groups. In the infection group, the fracture site was contaminated with Staphylococcus aureus (36 animals), whereas in the control group, there was no bacterial contamination (36 animals). No antibiotics were used either for prophylaxis or for treatment. We performed biomechanical (maximum torque causing failure and stiffness), radiographic (Lane and Sandhu scoring for callus formation), and histologic (scoring for callus maturity) assessments at 3 and 6 weeks. The number of bacteria colonies on the femur, wire, and soft tissue inside knee were compared to validate that we successfully created an infection model. The number of bacteria colonies in the soft tissue inside the knee was higher in the infection group after 6 weeks than after the third week, demonstrating the presence of locally aggressive infection.

RESULTS

Infection decreased callus strength at 6 weeks. Torque to failure (299.07 ± 65.53 Nmm versus 107.20 ± 88.81, mean difference with 95% confidence interval, 192 [43-340]; p = 0.007) and stiffness at 6 weeks (11.28 ± 2.67 Nmm versus 2.03 ± 1.68, mean difference with 95% confidence interval, 9 [3-16]; p = 0.004) both were greater in the control group than in the group with infection. Radiographic analysis at 6 weeks demonstrated the fracture line was less distinct (Lane and Sandhu score of 2-3) in the infection group and complete union was observed (Lane and Sandhu score of 3-4) in the control group (p = 0.001). Semiquantitative histology scores were not different between the noninfected controls and the rats with infection (score 10 versus 9).

CONCLUSIONS

Retaining an implant in the presence of an underlying infection without antibiotic treatment leads to weaker callus and impedes callus maturation compared with noninfected controls in a rat model. Future studies might evaluate whether antibiotic treatment would modify this result.

CLINICAL RELEVANCE

This model sets the stage for further investigations that might study the influence of different interventions on fracture healing in implant-associated osteomyelitis. Future observational studies might also evaluate the histological properties of callus in patients with osteomyelitis.

Ischial and pubic osteotomies performed by medial approach during periacetabular osteotomies: an anatomical study

OBJECTIVE

The aim of this study was to identify the anatomic landmarks of ischial and pubic osteotomies performed as part of Bernese periacetabular osteotomy, measure the distances of these landmarks to the main neurovascular structures and determine whether these osteotomies can be performed and visualized using a medial approach.

METHODS

The study included 20 hemipelvises of 10 formaldehyde-fixed cadavers. A medial surgical approach between the adductor longus and pectineus muscles was used, while protecting the obturator artery and nerve. The superior pubic ramus was subperiostally exposed to identify the anterior border of the anterior obturator tubercle and the projection point of the highest point of the obturator sulcus on the obturator crest as the two landmarks of pubic bone osteotomy. The line connecting the inferior border of the posterior obturator tubercle and the highest point of the ischial spine on the ischial bone was determined as the osteotomy line. Posterior dissection was carried out to measure the distance from the ischial osteotomy to the pudendal neurovascular structures. All measurements were performed using a digital caliper.

RESULTS

The mean distance from the obturator sulcus to the obturator nerve was 15.3 (range: 8.1 to 30.5) mm. The mean distance from the anterior obturator tubercle to the obturator nerve was 34.3 (range: 27.1 to 49.5) mm and to the obturator artery was 38.5 (range: 29.4 to 51.1) mm. The mean distance from the ischial osteotomy to the pudendal neurovascular structures was 13.6 (range: 11.2 to 17.6) mm.

CONCLUSION

The "pubic osteotomy line" connecting the anterior obturator tubercle and obturator crest, and the inferior border of the posterior obturator tubercle (the starting point of the ischial osteotomy line) can be approached and visualized safely using a medial incision in Bernese periacetabular osteotomy.

Short-term results of the Oxford phase 3 unicompartmental knee arthroplasty for medial arthritis

OBJECTIVES

We evaluated short-term results of the Oxford phase 3 unicompartmental knee arthroplasty (UKA) in patients with medial compartment arthritis.

METHODS

The study included 38 patients (28 females, 10 males; mean age 67 years; range 56 to 75 years) who underwent UKA for isolated medial knee osteoarthritis. At the time of surgery, 28 patients were in the age group of 56-64 years, and 10 patients were in the age group of 65-75 years. All the patients had Ahlbäck grade 2 primary medial compartment arthritis that had been unresponsive to conservative treatment. None of the patients had symptoms of patellofemoral arthrosis. Patients underwent UKA with the Oxford phase 3 cemented meniscal-bearing unicondylar prosthesis using minimally invasive surgery. The results were assessed preoperatively and at final controls according to the Knee Society clinical and functional rating system. Postoperative radiographic evaluations were made according to the Oxford criteria. The mean follow-up period was 24 months (range 18 to 32 months).

RESULTS

The mean preoperative active knee flexion increased from 121.8 degrees (range 110 degrees to 130 degrees ) to 130.9 degrees (range 120 degrees to 140 degrees) postoperatively (p<0.05). There was no limitation in knee extension both pre- and postoperatively. The mean preoperative and postoperative knee scores were 64.6 (range 47 to 80) and 97.5 (range 89 to 100), and the mean functional scores were 59.6 (range 45 to 80) and 92.1 (range 70 to 100), respectively (p<0.05). All the patients had an excellent knee score, while functional scores were excellent in 27 patients (71.1%) and good in 11 patients (28.9%). Postoperative radiographic measurements showed that the position of the femoral components was within acceptable ranges in all the patients with a mean of 3 degrees valgus (range 5 degrees valgus to 8 degrees varus) and 0.5 degrees extension (range 3 degrees extension to 2 degrees flexion). The positioning of the femoral components in relation to the mechanical axis was central in 30 patients and 2-mm lateral (range 2 mm medial to 4 mm lateral) in eight patients. The position of the tibial components was also within acceptable ranges in all the patients with a mean of 1.5 degrees varus (range 2 degrees varus to 2 degrees valgus) and a mean posterior inclination of 6.2 degrees (range 5 degrees to 7 degrees). All the tibial components showed full congruency with the medial, lateral, anterior, and posterior planes, except for one which had a 4-mm undersizing in the anterior plane. The polyethylene insert was central and parallel to the tibial component in all the patients. No osteophytes or cement debris that might lead to impingement were observed. All the components remained in position until the final controls. Complications such as insert dislocation, infection, pulmonary embolism, deep venous thrombosis, or neurovascular injury were not observed. None of the patients required revision surgery.

CONCLUSION

Our findings show that, with proper patient selection and strict adherence to the surgical technique, short-term results of the Oxford phase 3 unicompartmental knee prosthesis are excellent or good in the treatment of medial compartment osteoarthritis.

Large diameter metal-on-metal total hip arthroplasty for Crowe IV developmental dysplasia of the hip

The short-term results of middle-aged patients with severe developmental dysplasia of the hip treated with subtrochanteric femoral shortening and cementless large diameter metal-on-metal total hip arthroplasty were retrospectively evaluated. Clinical and radiological results of 15 hips of 13 patients with Crowe IV developmental dysplasia of the hip were enrolled in this study. The average follow-up period was 49 months (36-62 months). The average age of patients at the time of surgery was 45.5 years (range, 36-65 years). Radiographs were evaluated for component position, subsidence, loosening, and osteolysis. Intraoperatively, two patients had a small proximal femoral shaft split that was held with a cable wire. The average preoperative Harris hip score was 58; at 3 years, 82. Trendelenburg sign was negative in 11 hips at the last assessment. Loosening, subsidence, infection, dislocation, hypersensitivity and neurovascular complications were not observed. One hip had to be revised 1 year after surgery because of nonunion at the osteotomy site. Our study shows that large diameter metal-on-metal total hip arthroplasty, incorporating subtrochanteric femoral shortening, decreases dislocation rate and provides excellent results for the completely dislocated hip.

Anatomic course of the superficial branch of the radial nerve in the wrist and its location in relation to wrist arthroscopy portals: a cadaveric study

PURPOSE

The aim of this study was to assess the course of the superficial branch of the radial nerve (SBRN) at the level of the wrist and its branches in relation to wrist arthroscopy portals.

METHODS

Dissections were performed on 11 hands from 6 cadavers in the section starting from the point where the SBRN begins to emerge and ending at the terminal branches of the dorsal hand. The distribution of the SBRN, the distance from the superficial branch to the dorsal portals used in wrist arthroscopy, and the distance from the superficial branch to the anatomic determinants (styloid process of the radius, Lister tubercle) were studied.

RESULTS

At the level of the wrist, the nerve bifurcated into 2 branches in 8 of 11 wrists (73%) and into 3 branches in 3 of 11 wrists (27%). The mean distance from the SBRN where it was first detected proximal to the Lister tubercle was 73 mm. The mean distance between the styloids was 52 mm; the distance between the Lister tubercle and styloid process of the radius was 23 mm. At the wrist level, the distance from the branch closest to the radial side to the Lister tubercle was 28 mm (L-D1), 21 mm (L-D2/3), and 7 mm (RS-D1). The distance of the closest nerve branch to the 3-4 portal was 9 mm. The distances of the other portals were 5 mm (1-2RMC-D1), 8 mm (1-2RMC-D2/3), 8 mm (1-2P-D1), and 9 mm (1-2P-D2/3).

CONCLUSIONS

The limited size of the area where portals can be positioned and the anatomic variations between individuals are major obstacles in developing a guideline for reducing the risk of SBRN injury in wrist arthroscopy.

CLINICAL RELEVANCE

Great care must be taken when using the 1-2 portal. We suggest making a skin-only incision for this portal and then using blunt dissection to help prevent injury to the SBRN.

Closed reduction of the pediatric supracondylar humerus fractures: the "joystick" method

INTRODUCTION

Our goal in this study was to propose an alternative closed reduction method to avoid open reduction in the management of pediatric supracondylar humerus fractures. A temporary Kirschner wire is inserted to the proximal part of the humerus to be used as a joystick to have a better control of the proximal fragment.

PATIENTS

Twenty-three patients with closed Gartland type III extension fractures were operated between 2003 and 2007. Mean age of the patients was 6.7 (4-10) years.

METHOD

Uninjured and fractured elbow's Bauman angles, lateral condylar angles, the carrying angles and ROM values were compared statistically according to independent samples t test.

RESULTS

At a mean follow-up 96.73 weeks (53-150), clinical results using the Flynn criteria were excellent in 21 (91.3%), good in 1(4.35%), fair in 1 (4.35%) patient.

CONCLUSION

These results suggest that the "joystick" reduction method is a reliable alternative when closed reduction itself is not successful.

Minimally invasive management of unstable proximal femoral extracapsular fractures using reverse LISS femoral locking plates

The efficacy of the reverse Less Invasive Plating System in the management of unstable proximal femoral extracapsular fractures was retrospectively evaluated. Twenty-seven patients with complex proximal femoral fractures were identified. There were three open fractures. The mean age was 71 years (range; 65-79). The mean follow up was 24 months (range; 15-32). The main outcome measures were union, union time, requirement for secondary procedures, development of deep infection, pain, and functional impairment. Nonunion was observed in one patient. The average Harris hip score at the last assessment was 73 points (range 58-85). The outcome was adversely affected by concomitant medical problems, anatomical reduction and fixation of the plate. The use of this plate in the management of proximal femoral fractures of all types may be a safe and alternative method to other treatment options.

[Extramembranous transfer of the tibialis posterior tendon for the correction of drop foot deformity]

OBJECTIVES

We evaluated the effectiveness of extramembranous transfer of the tibialis posterior (TP) tendon for the treatment of drop foot deformity.

METHODS

The study included 13 patients (6 females, 7 males; mean age 30 years; range 10 to 46 years) who underwent 15 tendon transfers for drop foot deformity. Ten patients (76.9%) had deformity due to unrepairable nerve injuries, which were associated with surgical procedures in six patients and trauma in the remaining four. In four feet (26.7%), the TP tendon was turned from the intero-anterior aspect of the tibia and fixed by tenodesis to the lateral cuneiform bone, while in 11 feet (73.4%), it was transferred to the extensor hallucis longus, extensor digitorum communis, and peroneus tertius tendons. The patients were assessed according to the Stanmore system questionnaire. The mean follow-up was 25.3 months (range 12 to 80 months).

RESULTS

According to the Stanmore system, the results were poor in two feet (13.3%), moderate in three feet (20%), good in three feet, and very good in seven feet (46.7%). All the patients were satisfied with the final outcome. The mean foot dorsiflexion was 5 degrees (range, -5 degrees to 10 degrees ), which was 10 degrees in four feet (26.7%), and 5 degrees to 10 degrees in six feet (40%). Apart from complaints of bulging in four patients (30.8%) in the dorsum of the foot due to tendon and suture material, no complications were seen during the early postoperative period.

CONCLUSION

Extramembranous transfer of the TP tendon for the treatment of drop foot deformity enables the patients to walk without the aid of orthosis and increases their quality of life.

Ponseti technique for the correction of idiopathic clubfeet presenting up to 1 year of age. A preliminary study in children with untreated or complex deformities

INTRODUCTION

The aim of this study is to evaluate the effectiveness of the Ponseti method in children presenting before 1 year of age with either untreated or complex (initially treated unsuccessfully by other conservative methods) idiopathic clubfeet.

PATIENTS AND METHODS

The authors report 134 feet of 92 patients with Dimeglio grade 2, 3, or 4 deformities treated with the Ponseti method. Twenty-four percent of feet were of complex deformities at initial presentation to the authors' clinics.

RESULTS

At a mean follow-up of 46 months (range 24-89) we avoided joint release surgery in 97% of feet. Sixty-seven percent required a percutaneous tenotomy of the Achilles tendon. Relapse rate was 31% (41 feet). We treated 2 relapses by restarting the use of orthosis, 17 with re-casting, 18 with anterior tibial tendon transfer following a second relapse, and 4 feet with extensive joint surgery. Compliance with the use of orthosis was identified as the most important risk factor (P<0.0001) for relapses. Previous unsuccessful treatment attempts by other conservative methods did not adversely affect the results unless the cases had iatrogenic deformities. Cases with iatrogenic deformities from previous treatment had a significantly increased risk of non-compliance and relapse. Experience of the treating surgeon and cast complications were also related to relapses.

CONCLUSION

Our results show that the Ponseti technique is reproducible and effective in children at least up to 12 months of age. It can also produce good correction in children presenting with complex idiopathic deformities. Therefore, extensive joint releases should not be considered immediately in such cases. The treating surgeon should be meticulous in using the technique and ensure compliance to foot abduction brace in order to avoid recurrences.