Aim

The purpose of this study was to analyze the patellofemoral kinematics in neglected adult developmental dysplasia of the hip patients with patellofemoral symptoms and tried to clarify the affect of the severity of dislocation, the amount of limb length discrepancy, the deviation of mechanical axis and the changes in femoral anteversion on patellofemoral alignment.

Aim: This study was designed to investigate the role of VEGF in the etiopathogenesis of osteoporosis and to investigate its relation with bone mineral density (BMD) and other parameters.

Patients and Method: Bone scanning with Dual Energy X-ray Absorptiometry (DEXA) was performed to a total of 276 patients older than 40 years in our hospital’s radiology department. A total of 88 patients in accordance with the study criteria were included. 44 patients were female and 44 were male. These patients formed 4 groups; the osteoporotic males (MO) (group 1, n: 22, BMD −2.5 < ), the normal males (MN) (group 2, n: 22, BMD −1> ), the osteoporotic females (FO) (group 3, n: 22, BMD −2.5 < ), and the normal females (FN) (group 4, n:22, BMD −1> ). BMD measurements were performed with DEXA. Serum VEGF level was determined by the endogenous Human VEGF ELISA kit.

Results: The difference between male and female patient group in terms of serum VEGF levels was not statistically significant (p= 0.12). The difference among 4 groups in terms of serum VEGF levels was not statistical significant (p=> 0.05). There was a negative correlation between BMI and BMD in male patients. In MN cases age was negatively correlated with serum VEGF levels, BMI was negatively correlated with BMD, and BMD was negatively correlated with VEGF levels. Again in males, BMD was negatively correlated with VEGF values.

Conclussion: We think that the reason why they could not reveal statistically significant differences between osteoporotic and normal groups was their small sample size. Additionally difference between groups would be significant with larger sample size. As shown in the present study, the statistically significant negative correlation between BMD values and VEGF levels established in the male normal (MN) group and in the evaluation within the male population, suggest that VEGF could play a role in male osteoporosis.

Aim: The aim of the study was to assess the correlation of CE angle to the ratios of medial hip joint space width and femoral head diameter to acetabular width.

Material and metod: Measurements were done on 196 AP pelvic radiographs of 10 years old and 20 years old males and females obtained with “siemens lconos r 200 axion^®”. The patients were placed in the supine position with their hips extended and internally rotated 15°. Medial hip joint space width (mJSW), CE angle, femoral head diameter (FD) and acetabular width (AW) were measured. The intraobserver reproducibility was assessed by a randomly chosen subset of 50 radiographs and these were read 1 month apart. The levels of agreement were qualified using the intraclass correlation coefficient. The ratios of mJSW to AW and FD to AW were calculated.

Results: Mean CE angles in 10 years old females and males were 33.87±3.64 ve 32.74±4.21 degrees respectively. CE angle was correlated to mJSW/AW in 10 years old females (r = − 0.446, p=0.043). CE angle was not correlated to mJSW/AW in 10 years old males (r = − 0.293, p=0.146). CE angle was not correlated to mJSW/AW in 20 years old females while CE angle was correlated to mJSW/AW in 20 years old males (r = 0. 694, p=0.001). CE angle was correlated to FD/AW only in 20 years old males (r=0.553, p= 0.002).

Discussion: Ratios of medial hip joint space width and femoral head diameter to acetabular width are not correlated to CE angle in both preadelocent and postade-locent terms depending on sex. The expected inverse correlation of these parameters to CE angle was not dedected, so these parameters can be used in radiologic assessement of subluxation of the hip and acetabular dysplasia together with CE angle.

Aim: The aim of this study was to compare the treatment results of distal tibia shaft fractures treated with intramedullary nails with two different distal lockings and medial locking plates.

Patients and Method: Sixty-four patients with distal tibia fractures (4 to 11 cm proximal to the plafond) were operated with either unreamed intramedullary nails with medio-lateral distal locking (group A) or unreamed intra-medullary nails with both medio-lateral and antero-posterior lockings (group B), or medial locking plates (group C). There were 22 patients in group A, 22 patients in group B and 20 patients in group C. Mean age was 48.53±17.07 years. Mean follow-up was 26.68±7.02 months. At latest follow-up groups were compared for union time, malunion (defined as more than 5 degrees of angulation in any planes and/or any rotation and/or more than 5 milimeters of shortening), and delayed (lack of healing within 3 months) or nonunion (lack of healing within 6 months). Uninon was defined as healing of at least three of four cortices on AP and lateral radiographs.

Results: Mean union time was 17.45±4.22 weeks in group A, 16.71±4.90 weeks in group B and 15.73±3.26 weeks in group C. There was no significant difference between groups regarding union time. (p> 0.05) Malunion as defined was dedected in 4 patients in group A, in 4 patients in group B and in 1 patient in group C. There was no significant difference between groups regarding malunion rates. (p> 0.05). Delayed or non union was dedected in 6 patients in group A, in 5 patients in group B and in 1 patient in group C. There was no significant difference between groups regarding delayed or non-union. (p> 0.05). Two nonunions in group A and one nonunion in group B had to be treated with exchance reamed nailing. One infected nonunion in group C had to be treated with circular external fixation.

Conclusions: The results of surgical treatment of distal tibia fractures are similar with these three diifferent methods. Although malunion and delayed or nonunion rates are lower with medial locking plates, this is not significant.

Aim: This study was designed to investigate the association between clinical assessment International Clubfoot Study Group (ICFSG) and quantitative gait data of the children

Methods: Nineteen patients with 30 surgically treated clubfoot were included in this study. Bilateral involvement was present in 11. Average age was 9 years (range 6–14 years) at the time of last follow-up. Patients were treated with different surgical techniques at early childhood period. At the final follow-up they were evaluated according to ICFSG clinical scale. This rating system is based on three main subgroups of evaluation as morphologic evaluation, functional evaluation and radiological evaluation. The maximum score is 12 in morphologic evaluation, 36 in functional evaluation and 12 in radiological evaluation. The total score is from 0 for a perfect result to 60 for the worst result. Further, a total score of 0–5 is rated as excellent, 6–15 as good, 16–30 as fair and over 30 as poor. Quantitative gait data was collected with the Vicon 370 (Oxford Metrics, Oxford, UK). Two force plates (Bertec, Colombus, Ohio, USA) were used for kinetic analysis. All time-distance (walking velocity, cadence, step time, step length, double support time), kinematic (joint rotation angles of pelvis, hip, knee and ankle in sagittal, coronal and transverse planes) and kinetic (ground reaction forces, moments and powers of hip, knee and ankle) data were processed using Vicon Clinical Manager software package. Spearman correlation analysis was used to evaluate if there is a correlation between total clinical score and gait parameters.

Results: Average ICSG score was 8.63 (range 1–29). Outcome was excellent in 16, good in 8 and fair in 6 patients according to ICSG. There was a significant correlation between total ICSG score and walking velocity (rs=−0.195, p=0.004), step length (rs=−0.476, p=0.019), pelvic excursion in sagittal plane (rs=−0.429, p=0.026), hip excursion in sagittal plane (rs=−0.511, p=0.006), knee excursion in sagittal plane (rs=−0.486, p=0.019), Ankle excursion in sagital plane (rs=−0.413, p=0.040), peak ankle plantar flexion moment (rs=−0.600, p=0.039), peak ankle plantar flexion power (rs=−0.487, p=0.025). When we compare the gait parameters between groups only foot progression angle showed a significant difference (p=0.031).

Conclusion: ICFSG score is a successful method to follow outcome in patients with surgically treated clubfoot. ICFSG score is correlated with many kinematic and kinetic gait data however foot progression angle is the only parameter predicting outcome in children with surgically treated idiopathic clubfoot. Quantitative gait analysis may help to define the liable factors of the functional deficits, and to prescribe novel rehabilitation techniques to enable better outcome for children with clubfeet.

Aim: Surgical treatment for idiopathic clubfeet aims to realign the foot and allow plantigrade weight bearing with adequate joint motion. In spite of satisfying clinical and radiological results for both the physician and the parents shortly after the operation, deterioration may occur years after the surgery. The aim of this study was to evaluate gait characteristics of children with surgically treated unilateral clubfoot and had good clinical outcome.

Methods: Twelve children (mean age 5.9±2.3 years (4–9)) with surgically treated unilateral clubfoot before age one and twelve age matched healthy children were included in the study. Foot length, calf circumference, ankle range of motion and radiographic measurements were recorded. Quantitative gait data was collected with the Vicon 370 (Oxford Metrics, Oxford, UK). Two force plates (Bertec, Colombus, Ohio, USA) were used for kinetic analysis. All time-distance (walking velocity, cadence, step time, step length, double support time), kinematic (joint rotation angles of pelvis, hip, knee and ankle in sagittal, coronal and transverse planes) and kinetic (ground reaction forces, moments and powers of hip, knee and ankle) data were processed using Vicon Clinical Manager software package.

Results: Foot length of the operated side was shorter than the unaffected side but the difference was not significant (p> 0.05). Calf circumference and ankle range of motion were significantly less than the unaffected side (p< 0.05). Quantitative gait data revealed that children with clubfoot had slower walking velocity (0.75±0.25 versus 1.02±0.18 m/sec, p=0.001), shorter stride length (0.72±0.23 versus 0.91±0.05 meters, p=0.001) and less ankle plantar flexor moment (0.73±0.22 versus 0.88±0.11 m/sec, p=0.007) than healthy children. Unaffected side showed increased pelvic excursions and medio-lateral ground reaction forces as well as decreased ankle and hip motion in sagittal plane.

Conclusion: We detect various deviations in gait parameters even in so called well treated patients according to radiological and clinical criteria. Alterations in the unaffected foot may be the result of the subclinical involvement of the unaffected foot by disease as well as the compensatory mechanisms. These gait deviations may lead long-term morbidity later in adulthood.

Aim: The aim of this study is to evaluate the results of conservative treatment of Neer type III and IV fractures of the proximal humerus in patients who refused surgery or could not undergo surgery because of medical conditions.

Methods: Eighteen patients were included in the study. There were 8 Neer type III and 10 Neer type IV fractures. None of the patients had head-splitting fractures. Treatment and follow-up protocols were standardized for all cases. All patients were assessed for Constant scores in postoperative first year and at latest follow-up. Patients were divided into two groups regarding their age. Patients of 65 years or under that were named as group A (7 patients), while patients over 65 years old were named as group B (11 patients). Patients were further divided into two groups regarding their Constant scores. Patients with less than 70 points were named as group I (12 patients), while patients with 70 points or higher were named as group II (6 patients). Statistical analysis was performed using student’s t test, chi-square test and Fischer exact test.

Results: Mean age was 68.2± 13.8(39–90) years. Mean follow-up was 34.5±12.4 (18–56) months. Mean Constant score was 56.1±14.7 (26–76) points in postoperative first year follow-up. Mean Constant score was 59.7±13.9 (36–84) points at latest follow-up. Osteonecrosis of the humeral head was dedected in 5 patients. There was no significant difference between group A and group B regarding Constant scores (p=0.233). There was no significant difference between group I and group II regarding age (p=0.178). There was no significant difference between Neer type III and Neer type IV fractures regarding age (p=0.176) and Constant scores (p=0.075). Mean postoperative first year Constant score of Group A patients with type III fractures was significantly higher when compared to group B patients with type IV fractures (p=0.046). Constant scores at latest follow-up (p=0.261) and fracture types (p=0.618) were similar between patients with osteonecrosis and without osteonecrosis.

Conclusions: Results of conservative treatment of these fractures are satisfactory even in elderly patients. Similar functional results as in younger patients can be achieved with proper and accurate treatment. While fracture type individually does not have an influence on functional results, functional results are better in young patients with type III fractures then in old patients with type IV fractures.

Aim: Complete tenotomy was performed on the most important flexor hip muscle; namely the iliopsoas during open reduction in patients with developmental dysplasia of the hip (DDH). The iliopsoas and other flexor-extensor muscles in operated and contralateral hips were evaluated comparatively by magnetic resonance imaging (MRI).

Methods: A total of 22 patients with unilateral DDH after the walking age and treated with one-stage combined surgery were analyzed. All patients were operated by the same surgeon with complete tenotomy of iliopsoas muscle hindering open reduction. All patients had functionally excellent results in accordance with the Barrett’s Modified McKay Criteria in their last follow-up visits and according to Severin’s classification all cases were type 1. The imaging was performed by 1,5 T GE Excite MRI device at the supine position, without contrast material and sedation. The sagittal sections for iliopsoas muscle and T2-W FSE axial images for flexor and extensor muscle groups were used. The operated and contralateral sides were compared. Student’s t test, paired t test, and Spearman’s Rank correlation analysis were used for statistical assessment.

Results: The mean age was 12,8±2,9 (9–18) years old. The mean postoperative follow-up period was 112,6 ± 32,0 (68–159) months. The reattachment of the iliopsoas to trochanter minor was observed in 7 patients, with no significance in terms of age, postoperative follow-up period, and the duration of postoperative period (p> 0,05). The atrophy in the operated side was significant in the length of iliopsoas muscle section area (p=0,0001); and the section areas of rectus femoris (p=0,002), tensor fascia lata (p=0,0001), and gluteus maximus (p=0,0001). No significance was detected in sartorius muscle section area (p=0,886). However, unlike other muscles; the ratio of operated versus contralateral side mean muscle section areas was above 1 (1,1± 0,3) for the sartorius muscle. Iliopsoas muscle reattachment was not significant for ratios of the other muscles’ operated versus contralateral side muscle section areas (p> 0,05). The atrophy was significant for the second (p=0,03) and the third (p=0,022) section’s diameter ratios in the non-reattachment versus reattachment group for the iliopsoas muscle.

Conclusion: The reattachment of the iliopsoas muscle to trochanter minor after complete tenotomy was observed in 32% of patients. Following complete iliopsoas tenotomy, the expected compensatory hypertrophy in other flexor hip muscles was not detected. At the operated side, all evaluated muscles were atrophic except for the sartorius muscle. The atrophy of iliopsoas muscle was significant for the operated hip with non-reattachment to insertion site versus reattachment group.

Aim: In patients without infections following primary total hip (PTHA) and knee (PTKA) arthroplasty, the natural course of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were evaluated. The effects of gender, anesthesia type, cementing, and tourniquet use on the natural course of CRP and ESR were determined. Understanding the natural course of plasma ESR and CRP is helpful in terms of the diagnosis and follow-up of infections, especially in the early postoperative period.

Methods: A total of 82 patients with normal preoperative CRP and ESR, both in accordance with gender and age; without any chronic condition, infection, or inflammatory disease; and with no intra–and post-operative complications were included. PTHA was performed on 38 (Groups I–II) and PTKA on 44 patients (Groups III-IV). CRP and ESR measurements were performed on the 1st preoperative day; 1st, 2nd, 3rd, 5th, 7th, 14th, and 21st postoperative days; and the 1st, 2nd, 3rd, 6th, 9th, and 12th months. CRP measurements were performed with the nephelometric (Dade Behring S.p.A., Italy) and quantitative Methods: Westergren method was used for ESR measurements. The PTHA group was further classified as femoral component fixed with (Group I; 28 patients) and with-out cement (Group II; 10 patients), while PTKA as with (Group III; 32 patients) and without tourniquet (Group IV; 12 patients). Furthermore, epidural (Group IIIa) and general anesthesia (Group IIIb), and gender differences (Group Ia; female and Group Ib; male) were compared. Wilcoxon test, paired-t test, Students’-t test, ANOVA, and chi-square tests were used for statistical analysis.

Results: After the operation, separate peak CRP and ESR levels of each patient and days of reaching peak and normalization were evaluated. When the mean of peak CRP levels were compared, groups III and IV had significantly higher levels with regard to groups I and II (p=0.037), However, the days of reaching peak levels were statistically similar between PTHA and PTKA groups (p=0.245). The same comparison was repeated for the mean of peak ESR levels, the results were similar (p=0.547). In cemented PTHA, CRP normalized earlier than cementless PTHA and PTKA (p=0.035) and ESR also normalized earlier, but this was not significant (p= 0.074). Among groups comparing gender and anesthesia type, mean values of CRP and ESR peaks, distribution of these two levels on the days controlled, and days of reaching peaks and normalization were statistically similar (p> 0.05).

Conclusions: In the PTKA group, the mean CRP peak was higher than PTHA. CRP levels normalized earlier in cemented PTHA cases. Anesthesia type, gender differences, and use of tourniquet in PTKA did not affect the course of CRP and ESR following arthroplasty.

Aim: Patients treated with one-stage combined operations after walking age for developmental dysplasia of the hip (DDH), and whose follow-up revealed both clinical and radiological complete healing underwent flexor and extensor isokinetic muscle strength (IMS) measurements of the hip and results were evaluated in comparison with the contralateral hips.

Methods: A total of 22 patients with unilateral DDH and treated with one-stage combined operations after walking age were included in the study. All patients were operated by the same surgeon. In their last follow-up visit, all patients were functionally excellent in accordance with the Barrett’s Modified McKay Criteria and according to the Severin’s Classification for radiological grading of the hip all cases were type I. IMS of hip flexors and extensors were tested by Biodex 3 Pro isokinetic test device at 120º/sc and 240º/sc. In all patients, peak torque (PT), peak torque angle (PTA), total work (TW), and average power (AP) values of operated and non-operated hips were measured at both angular velocities and recorded separately for flexors and extensors. For comparative evaluation, values of the operated and non-operated hips were used for determining the differences in IMS (DIMS), total work (DTW), and average power (DAP). In statistical assessment; Student’s t test, paired t test, and Spearman’s Rank correlation analysis were used.

Results: The mean age of patients were 12,8±2,9 (9–18) years old. At the last control visit, the mean value of follow-up periods were 112,6±32,0 (68–159) months. Parameters like age, age at the time of operation, and the length of postoperative follow-up period showed no statistical relation with IMS measurements (p> 0,05). For flexors, TW was lower at the operated hip when compared with the non-operated hip at 120º/sc and 240º/sc (p=0,001 and p=0,002, respectively). AP was lower at the operated hip at 120º/sc and 240º/sc (p=0,011 and p=0,003, respectively). PT was lower at the operated hip (22,5±11,3) when compared with the non-operated hip (27,1±12,1) only at 120º/sc (p=0,001). For extensor muscles, PT, TW, AP, and PTA showed no statistically significant difference (p> 0,05). For flexors, the DIMS between operated and non-operated hips at 120º/sc and 240º/sc were measured as −15,3±22,2% (median;-14,4) and −8,0±21,4% (median;−2,5), respectively.

Conclusions: In operated DDH patients with a mean follow-up period of around 10 years, IMS measurements revealed that the flexor muscle strength of the operated hip was still weaker than the non-operated hip. At 120º/sc, which represented evaluation against higher resistance, DIMS, DWF, and DAP were higher when compared with 240º/sc. This finding shows that hip flexors of these patients may remain weak in activities like sports, which require more resistance.