Evaluation of structural changes in tarsal bones following complete subtalar release for congenital clubfoot

Amaç: Tek taraflı doğuştan çarpık ayak (DÇA) nedeniyle tam subtalar gevşetme ameliyatıyla başarılı sonuç alınan olguların orta dönem izleminde tarsal kemik değişiklikleri bilgisayarlı tomografi (BT) ile değerlendirildi. Hastalar ve yöntemler: Çalışmaya 1990-1995 tarihleri arasında tek taraflı DÇA nedeniyle tam subtalar gevşetme uygulanan dokuz hasta (5 erkek, 4 kız; ort. yaş 12; dağılım 9-14) alındı. Tüm olgularda iyileşme Simons kriterlerine göre iyi derecedeydi. Ortalama 10.5 yıl (dağılım 8-13 yıl) olan izlemden sonra olguların normal ve ameliyatlı ayakları düz grafilerle ve standart ve üç boyutlu BT ile incelendi. Bu görüntülerde tarsal kemik değişiklikleri niceliksel ve niteliksel olarak değerlendirildi. Bulgular: Aksiyel BT kesitlerinde sekiz olguda naviküler kemikte dorsala subluksasyon, yedi olguda naviküler kemikte kamalaşma, dört olguda talus başında düzleşme, üç olguda naviküler kemiğin lateral kısmında yassılaşma, iki olguda talonaviküler eklem aralığında azalma, iki olguda talonaviküler temas alanında azalma görüldü. Sağlam tarafta talus hacmi ortalama 29.3 mm3 ve naviküler kemik hacmi 8.5 mm3 iken ameliyatlı ayaklarda bu değerler sırasıyla 24.0 mm3 (p=0.008) ve 7.0 mm3 (p=0.01) bulundu. Sonuç: Doğuştan çarpık ayak nedeniyle cerrahi tedavi uygulanan ve klinik ve fonksiyonel olarak normale yakın sonuçlar elde edilen ayaklarda bile tarsal kemiklerde yapısal değişiklikler ortaya çıkmaktadır. Bu değişimlerin daha uzun dönemde klinik bulguları nasıl etkileyeceğinin araştırılması gerekir.Objectives: We evaluated the mid-term radiologic changes in tarsal bones by computed tomography (CT) in patients in whom complete subtalar release for congenital unilateral clubfoot resulted in a successful outcome. Patients and methods: The study included nine patients (4 girls, 5 boys; mean age 12 years; range 9 to 14 years) who underwent complete subtalar release for congenital unilateral clubfoot between 1990 and 1995. According to the Simons criteria, a satisfactory outcome was obtained in all the patients. After a mean follow-up of 10.5 years (range 8 to 13 years), all the feet were studied by plain radiographs and standard and three-dimensional CT. Changes in tarsal bones were evaluated and compared with the normal side. Results: Axial CT scans showed dorsal navicular subluxation in eight feet, wedge-shape formation in the navicular bone in seven feet, flattening of the talar head in four feet, flattening of the lateral part of the navicular bone in three feet, narrowing of the talonavicular joint distance in two feet, and decrease in the talonavicular contact area in two feet. Significant differences were found between the operated and the contralateral feet with respect to the mean volumes of the talus (24.0 mm3 vs 29.3 mm3,p=0.008) and the navicular bone (7.0 mm3 vs 8.5 mm3, p=0.01). Conclusion: Structural changes in tarsal bones may occur following surgical treatment of congenital unilateral clubfoot despite achievement of satisfactory clinical and functional results. Further studies are required to understand how these changes will influence the clinical condition of the foot in the long-term

Intraarticular Giant Size Angiolipoma of the Knee Causing Lateral Patellar Dislocation

Background: Angiolipomas are benign tumors usually seen in patients during their 2nd and 3rd decades. The subcutaneous region of the trunk, neck and extremities are the places where they generally settle. There is only one case report on angiolipoma in the knee joint that was resected by arthroscopic procedure in the English literature. Case Report: We present a case of a giant-size multilobular non-infiltrating angiolipoma, extending outside of the right knee joint and causing lateral patellar dislocation in a thirteen-year-old boy. A large encapsulated mass with fatty and soft-tissue components on magnetic resonance imaging was suggestive of a liposarcoma. However, the diagnosis after the tru-cut biopsy was angiolipoma. The Quadriceps angle was 25°. Complete resection of the tumoral mass and repair of the medial retinaculum were performed with open surgery. Patellofemoral alignment was provided by transferring the tibial tuberosity medially. One year after the surgery, there was no evidence of recurrence. Conclusion: Intra-articular angiolipomas are rarely seen masses in the knee joint. To our knowledge, this case report is the first to demonstrate that angiolipoma causes patellar dislocation

Evaluation of symphysis pubis and sacroiliac joint distances in skeletally immature patients: A computerized tomography study of 1020 individuals

Objective: The aim of this study was to create a reference about normal pubic symphysis and sacroiliac joint widths of children and adolescents. Methods: A total of 1020 computerized tomography axial scans of patients without pelvic injury between 2 and 18 year-old were studied. The narrowest width of pubic symphysis and bilateral sacroiliac joints were measured. Results: The average pubic symphyseal width at 2 years old boys was 6.35 ± 1.06 mm (4.88–9.13 mm). The average of right and left sacroiliac joints' widths at 2 years old boys was 4.56 ± 0.65 mm (3.59–6.07 mm) and 4.58 ± 0.66 mm (3.44–5.74 mm), respectively. The average pubic symphyseal width of 2 years old girls was 5.85 ± 1.14 mm (4.06–8.20 mm). The average of right and left sacroiliac joints' widths at 2 years old girls was found 4.36 ± 0.56 mm (3.50–5.37 mm) and 4.42 ± 0.59 mm (3.58–5.73 mm), respectively. The average pubic symphyseal width at 18 years old boys was found 3.68 ± 1.30 mm (1.90–5.79 mm). The average of right and left sacroiliac joints' widths at 18 years old boys was found 1.97 ± 0.21 mm (1.73–2.41 mm) and 2.04 ± 0.30 mm (1.70–2.65 mm), respectively. The average pubic symphyseal width at 18 years old girls was 3.92 ± 0.52 mm (2.97–4.76 mm). The average of right and left sacroiliac joints' widths at 18 years old girls was found 2.34 ± 0.40 mm (1.58–3.34 mm) and 2.33 ± 0.37 mm (1.58–3.10 mm), respectively. Conclusion: Our results suggest that one should be suspicious about pelvic injury if the width of pubic symphysis is over 10 mm and width of sacroiliac joint is over 8 mm especially in patients younger than 10 years-old. Level of Evidence: Level III Diagnostic study. Keywords: Pubic symphysis, Sacroiliac joint, Measurement, Pediatric, Computerized tomograph

Assessing the role of hip arthrography in the treatment decision making forchildren with Legg-Calvé-Perthes disease

Objective: The aim of this study was to determine the role of hip arthrography in the treatment decision making for children with Legg-Calvé-Perthes disease (LCPD).Methods: A total of 47 consecutive children with LCPD (42 boys, 5 girls; mean age=7.5 years; range=6-10 years) who underwent operative treatment were included in the study. The patient demographics, physical examination findings (pain and hip range of motion [ROM]), standard anteroposterior and Löwenstein lateral hip radiographs, and hip arthrography data were retrospectively collected. The arthrographies were performed immediately before the surgery under general anesthesia. The patients were staged according to the Catterall and Herring classifications and examined in terms of head-at-risk signs before the study. Four sets of patient files were established based on the aforementioned data, with each child in a randomized and blinded order. Ten consultant pediatric orthopedic surgeons randomly assessed the patient files on 4 separate occasions (Set 1 vs Set 2 and Set 3 vs Set 4), with a minimum time interval of 4 weeks. In the first and second sets, the demographic and clinical information, including the age, gender, hip ROM, and hip radiographs, were presented. In the third and fourth sets, hip arthrography was presented in addition to the data from Set 1 and Set 2. The observers were instructed to choose the best treatment options. The percent agreement (PA) and Gwet’s AC1 statistics were used to establish a relative level of agreement among the observers. Results: The mean intra-observer reliabilities ranged from fair to moderate after adding the hip arthrography data (Gwet’s AC1 = 0.36 for Set 1 vs Set 2 and 0.42 for Set 3 vs Set 4). The mean PA was 56.6% (range = 29.8% to 78.7%) with a Gwet’s AC1 value of 0.51 (range: 0.21 to 0.77) between Set 1 and Set 3 (moderate intra-observer reliability). The decision for the treatment strategy was changed in 43.4% of the patients. For inter-observer reliability, Gwet’s AC1 was computed as 0.48 (moderate reliability). The correlation between the intra-observer reliability and stage progression was not significant (p>0.05) for any of the subgroups. Thus, there is a negative correlation with the disease progression.Conclusion: Hip arthrography seems to have a significant role in the treatment decision making for children with LCPD, especially in the advanced stages of the disease.Level of Evidence: Level IV, Therapeutic stud

Is surgeons' experience important on intra- and inter-observer reliability of classifications used for adult femoral neck fracture?

Purpose: To evaluate whether surgeons' experience affect inter- and intra-observer reliability among mostly used classification systems for femoral neck fractures. Material and methods: A power point presentation was prepared with 107 slides which were antero-posterior radiographs of each femoral neck fracture. Five residents, 5 orthopaedic surgeons and 5 senior orthopaedic surgeons reviewed this presentation and classified the fractures according to Garden, Pauwels and AO classifications. The order of the slides was changed and reviews were repeated after 3 months. Fleiss kappa and intraclass correlation coefficient values were calculated to evaluate inter and intra-observer reliability. Results: Garden and AO classifications' inter-observer reliabilities were similar and higher than Pauwels classification. Among three experience groups, the inter-observer reliability for Garden classification was highest in senior surgeon group, the interobserver reliability for AO classification was highest in surgeon group, and interobserver reliability of Pauwels classification was highest in low experienced groups (residents and surgeons). Intra-observer reliability was highest for Garden and lowest for Pauwels classifications. Surgical experience was found to be not effective for intraobserver reliability. Conclusion: Both Garden and AO classifications were more reliable than Pauwels classification. Surgical experience was not significantly important on these three classification systems' evaluation.Level of Evidence: Level IV, Diagnostic study Keywords: Femoral neck fracture, Classifications, Reliability, Experienc