Intraobserver and Interobserver Reliability of the Computed Tomography-Based Classifications Used in Posterior Malleolar Fractures: The Haraguchi and Bartoníček-Rammelt Classifications

BACKGROUND

Three main computed tomography (CT)-based classification systems have been defined and used for posterior malleolar fractures. The intraobserver and interobserver reliability of two of these systems has never been investigated. The aim of this study was to investigate the intraobserver and interobserver reliability of the Haraguchi (HC) and Bartoníček-Rammelt (BRC) classifications.

METHODS

Axial and sagittal CT sections and three-dimensional reconstruction images of 60 fractures were evaluated twice by six observers at a 6-week interval. Cohen κ values for intraobserver reliability and Fleiss κ values for interobserver reliability were calculated.

RESULTS

The interobserver reliability of the HC was fair in both assessments (Fleiss κ: 0.263 and 0.249 for the first and second evaluations, respectively). The interobserver reliability of the BRC was moderate in both evaluations (Fleiss κ: 0.535 and 0.447, respectively). The intraobserver reliability values (Cohen κ) of the HC were determined to be between 0.532 and 0.927 for the six observers. These values indicated moderate agreement for one observer, substantial for four, and very good for one. Intraobserver reliability values for the BRC were determined to be between Cohen κ of 0.626 and 0.884. Based on these values, the BRC's intraobserver reliability indicated substantial agreement for two observers and very good for four observers.

CONCLUSIONS

Intraobserver and interobserver reliability values of the BRC were higher than those of the HC.

Does the size of Thurston-Holland fragment have an effect on premature physeal closure occurrence in type 2 distal tibia epiphyseal fractures?

The purpose of this study was to investigate the possible effect of Thurston-Holland fragment (THF) size on the development of premature physeal closure (PPC) in distal tibia type 2 epiphyseal injuries. Fifty-eight fractures in 57 patients with a minimum follow-up period of 12 months were included. For statistical analysis, sex and age of the patient, number of reduction attempts, percentage of THF base relative to physis length on anteroposterior or lateral radiograph, maximal initial and postreduction displacement amount, presence of accompanying fibula fracture and trauma mechanism were evaluated. PPC was observed in 12 fractures (20.7%). An increased amount of initial displacement, increased number of reduction attempts and passing the physis with three Kirschner wires were determined as statistically significant factors for PPC occurrence (P = 0.011, 0.011 and 0.005, respectively). The THF percentage was not found to be an important factor for the occurrence of PPC. In males, THF size was less than 50% more frequently than that in females (P = 0.013). THF size had no significant effect on PPC occurrence after distal tibial epiphyseal fractures.

Analysis of the factors that are important in re-displacement in pediatric diaphyseal femur fractures treated with a spica cast

BACKGROUND

There is no detailed data on the factors affecting the re-displacement in pediatric femoral fractures treated with closed reduction and early spica casting. This study aimed to investigate the factors effective in re-displacement in pediatric diaphyseal femur fractures (PDFF) treated with spica casting.

METHODS

In all, 151 displaced PDFF were evaluated retrospectively. Demographic data of the patients were evaluated. Type of fractures, anteroposterior and lateral angulations, amount of shortening, translation ratio, cast index (CI), gap index (GI), and three-point index (TPI) measurements were evaluated radiologically. Thigh flexion angle (TFA) and knee flexion angle (KFA) were measured. After casting, angulation of more than 10° in any plane and a shortening of more than 10 mm was accepted as re-displacement. Binary logistic regression analysis was used to evaluate the risk factors of re-displacement. Receiver operating characteristic analysis was performed for TFA and KFA.

RESULTS

Re-displacement was detected in 40 patients (26.5%). Transverse type fracture (p = 0.001), TFA ˂71.4° (p <0.001), and KFA ˂52.6° (p = 0.002) were found to be statistically significant factors on re-displacement. It was determined that the combination of transverse femoral fracture and TFA ˂71.4° increased the probability of re-displacement by approximately 14 times. It has been observed that indices such as CI, GI, and TPI were not effective in predicting the risk of re-displacement.

CONCLUSION

When treating a PDFF with spica casting, one should be aware of re-displacement if the fracture type is transverse, TFA is ˂71.4°, and KFA is ˂52.6°.

LEVEL OF EVIDENCE

Level III, prognostic.

The influence of anesthesia-body mass index and chronicity of the injury on the reliability of diagnostic tests for anterior cruciate ligament rupture

This study aimed to analyze the accuracy and interobserver reliability of the four common diagnostic tests for anterior cruciate ligament (ACL) rupture. The effect of anesthesia, chronicity of the injury and patient’s body mass index (BMI) on the reliabilities was also assessed. Patients who underwent arthroscopic knee surgery were examined before the surgery and under anesthesia by three observers categorized based on their experience levels. One hundred two patients were evaluated to determine the accuracy of these tests. Sixty-two patients with ACL rupture were further examined to assess the effect of BMI (≤25 kg/m², or >25 kg/m²) and chronicity (≤4 or >4 weeks) of the injury on reliabilities with using the Fleiss kappa method. The Lachman test performed under anesthesia had the highest sensitivity (100%, 100%, and 96.7%). In contrast, pivot shift and lever sign tests had the lowest sensitivity both in awake (24.2%, 17.7%, 8.1% and 37.1%, 33.8%, 29%) and anesthetized condition (75.8%, 75.8%, 67.7% and 41.9%, 43.5%, 40.3%). Specificities of the tests except pivot shift were negatively affected when performed under anesthesia. The reliability of the anterior drawer test was perfect under anesthesia. The lever sign test had the highest reliability in the awake condition in patients with a BMI of >25 kg/m². Furthermore, the reliabilities of the anterior drawer, Lachman, and pivot-shift tests in awake condition were found to be increased in patients with a chronic injury. Finally, the examiner’s experience is not important for the physical diagnosis of ACL rupture.

Reliability of Evaluation of the Surgeon-Dependent Factors Affecting Mechanical Failure after Intertrochanteric Femur Fracture Treatment

PURPOSE OF THE STUDY The intertrochanteric femur fractures seen in the elderly population are usually treated surgically. Mechanical failure of this treatment is a serious complication and to prevent this, many assessment factors have been described such as tip-apex distance, reduction quality etc. The aim of this study is to evaluate the intra- and inter-observer reliability of modifiable factors evaluated after the treatment of intertrochanteric fractures. MATERIAL AND METHODS The early post-operative radiographs of sixty-two patients treated with PFN-A were evaluated. Six observers with 8 to 27 years of experience in hip trauma surgery were asked to measure tip apex distance (TAD), calcar referenced TAD (calTAD), collo-diaphyseal angle (CDA) and evaluate the position of helical blade and also fracture reductions according to Baumgaertner and Chang criteria on these radiographs. Fleiss kappa and intra-class correlation coefficient (ICC) values were calculated for inter-observer and intra-observer reliability assessment, respectively. RESULTS Inter-observer reliability values for both evaluations were moderate (fleiss κ: 0.417-0.455) for TAD measurements, moderate (fleiss κ: 0.418-0.458) for calTAD measurements, fair (fleiss κ: 0.302-0.288) for CDA measurements, substantial (fleiss κ: 0.606-0.631) for antero-posterior zone evaluation, moderate (fleiss κ: 0.550-0.546) for lateral zone assessment, fair-moderate (fleiss κ: 0.353-0.453) for Baumgaertner reduction quality assessment, and fair-moderate (fleiss κ: 0.365- 0.456) for Chang reduction quality assessment. Intra-observer reliabilities were found to be moderate to good for TAD and calTAD measurements, moderate for CDA measurements, good to excellent for AP and lateral zone and Baumgaertner reduction quality criteria assessments and good for Chang reduction quality criteria assessment. DISCUSSION There is no large data on the subject of the present study in the literature. There is a single article evaluating the reliability of more than one evaluation criteria in which only two observers' findings were evaluated in the literature. As in our study, more accurate inferences can be made with the increase in the number of observers. Unlike the literature, the inter-observer reliabilities of TAD and calTAD which have a very important place in the postoperative evaluation of these fractures were found as "moderate'' instead of "excellent'' in our study, CONCLUSIONS It was determined that only the inter-observer reliability of antero-posterior zone evaluation was substantial. The inter-observer reliability of all other measurements and evaluations were fair to moderate. Key words: Intertrochanteric fractures, reliability, measurements, reduction quality; TAD, calTAD.

Ankle Joint Injuries Accompanying Fifth Metatarsal Base Fractures

BACKGROUND

Fifth metatarsal base fractures are the most commonly seen fractures of the foot. Ankle sprains occur with inversion and plantarflexion mechanisms, similar to most fifth metatarsal base fractures. We sought to investigate the possible ankle injuries that accompany fifth metatarsal base fractures.

METHODS

A hospital's digital database was searched for the International Classification of Diseases, Tenth Revision codes for metatarsal bone fractures (codes S92.30 and S92.35) between January 2015 and January 2018. Thirty-nine patients with fifth metatarsal base fracture who underwent ankle magnetic resonance imaging (MRI) within 14 days of injury were included in the study. The MRI findings were evaluated, and comparisons were performed according to fracture zone, sex, and age.

RESULTS

The most common MRI finding was talocrural joint effusion, which was observed in 28 patients (71.8%). Bone marrow edema was observed in 16 patients (41.0%). Chondral injury at the medial dome of talus was observed in three patients (7.7%). Grade 1 ligament sprain was observed in six patients (15.4%): two in the lateral ligament and four in the deltoid ligament.

CONCLUSIONS

Although most fifth metatarsal base fractures and ankle sprains occur as a result of a common mechanism, physical examination findings and patients' complaints are very important. Routine MRI should be unnecessary for most patients. If a patient with a fifth metatarsal base fracture has complaints about the ankle joint, one should be aware of bone marrow edema, which was observed in 41.0% of the study population.

Direct Radiography Following Fracture Reduction Improves the Reliability of Pauwels Classification

PURPOSE OF THE STUDY Pauwels classification system is widely used to classify the femoral neck fractures. Even its widely usage there are severals debates about its reliability. After the femoral neck fracture occured the lower extremity rotates externally and this external rotation deformity could lead to misevaluation of Pauwels angle at the initial radiographs. The purpose of our study is to investigate whether the reliability of Pauwels classification increases after reduction of femoral neck fractures. MATERIAL AND METHODS Two power point presentation was prepared with 117 slides that include antero-posterior radiographs of each femoral neck fracture. The first one included preoperatively taken radiographs and the second one included early postoperatively taken radiographs. Eight observers evaluated these radiographs and they classified the fractures according to Pauwels classification system. After 3 months, the order of the slides were changed for each presentation and the observers were asked to evaluate the radiographs again. Intraclass correlation coefficient values were calculated for evaluation of inter- and intra-observer reliability. RESULTS The mean intra-observer agreement of preoperative evaluation was 0.406 (0.071-0.626) and the interobserver agreements were 0.263 (0.197-0.342) and 0.359 (0.287-0.447), respectively. The intra-observer agreement of postoperative evaluation was 0.508 (0.393-0.757), inter-observer agreements were 0.427 (0.353-0.509) and 0.431 (0.356-0.513), respectively. According to preoperative and postoperative evaluations, 6 of 8 observers' intra-observer agreements were found to be increased and the remaining 2 decreased. Interobserver reliability was improved from poor to fair-good values after evaluating the reducted fracture radiographs. DISCUSSION Femoral neck fractures(FNF) are common and anatomical reduction and internal fixation are preferred as a treatment option in young people and patients have good bone quality. Pauwels classification system is used for classify the FNF based on the shearing angle of the fracture line. As this angle increases, the fracture becomes unstable and nowadays stronger fixation devices are preferred for unstable fractures. Therefore, misevaluation of the fracture can lead to wrong treatment method selection. Non-optimal X-rays taken in the emergency rooms may cause misinterpretation of femoral neck fractures according to Pauwels classification system. We hypothized that the reliability of this classification system could be improved after reduction of the fracture. CONCLUSIONS Our study showed that classifying the femoral neck fracture according to Pauwels classification system is more confidential after the reduction, however we can not state that it's reliability is adequate. Key words: femoral neck fracture, Pauwels classification, reliability, inter-observer, intra-observer.

Instant messaging application usage for clinical consultation among orthopedic surgery residents in Turkey: A survey study

OBJECTIVE

This study aimed to determine the characteristics of instant messaging application (IMA) usage for clinical consultation among orthopedic residents in Turkey and to explore their experiences and opinions concerning potential legal problems.

METHODS

A questionnaire titled "Instant messaging for consultation among orthopedic surgeons" consisting of 21 questions was applied to orthopedic surgery residents, and the results were analyzed. The questions were designed to obtain information on 4 categories: 1) demographics and professional experience, 2) attitudes on the use of cellular phones, 3) IMA usage for clinical consultation purposes, and 4) problems and comments on smartphone application usage for clinical consultation purposes. The participants who had no experience with a smartphone or IMA usage were excluded at the final analysis.

RESULTS

A total of 860 orthopedic residents (849 males [98.7%]; mean age=28.6 years; age range=22-44 years) participated in the survey (participation rate: 97.3%). The distribution of residency years was as follows: 1st year, 27%; 2nd year, 21.4%; 3rd year, 18.4%; 4th year, 17.4%; and 5th year, 49.9%. The most frequently used IMAs were WhatsApp (99.3%), Facebook Messenger (14.8%), Viber (8%), and Tango (1.3%). The rate of IMA usage for consultation was 95.3%. The most common reasons to prefer IMAs for consultation were being "fast" and "easy," but only 26.3% of the residents reported that they prefer the use of IMAs because they find them "reliable." Moreover, 41.7% of the respondents reported that they had an experience of misdiagnosis owing to the use of IMAs; 81.2% of the participants used the personal information of the patients during the consultation; 57.6% of the respondents considered that legal problems may arise because of the use of IMAs during the consultation; and 51.4% believed that an electronic platform, solely for consultation purposes, is required.

CONCLUSION

This survey has shown that it is necessary to make some legal regulations regarding the use of IMAs for consultation purposes and to develop applications only for medical consultation purposes. Most of the trainees make decisions using IMAs without a proper examination, putting the patients at the risk of misdiagnosis. Moreover, the confidentiality of the patient's personal information appears to be in danger when IMAs are used.

LEVEL OF EVIDENCE

Level IV, Diagnostic Study.

Assessing the role of hip arthrography in the treatment decision making for children 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 study.

Effect of COVID-19 pandemic on the fracture demographics: Data from a tertiary care hospital in Turkey

OBJECTIVE

The purpose of this study was to evaluate the types and the frequency of fractures, both in the pediatric and adult population during the COVID-19 pandemic and to find out the differences in comparison to the non-pandemic period.

METHODS

Patients who were admitted to the hospital with a new fracture during pandemic period (March 16 to May 22, 2020) were evaluated. Control group consisted of patients with new fractures admitted to the hospital in the same date range in 2018 and 2019. The patients were divided into two groups as ≤16 years old (group 1) and >16 years old (group 2). The evaluation was based on the age and gender of the patients and localization of the fractures. Hospitalized and surgically treated patients were evaluated as well.

RESULTS

A total of 1794, 1747, and 670 fractures were observed in 2018, 2019, and 2020, respectively. Mean age of the patients in group 1 was found to have decreased in the pandemic period (p<0.001). The most common fracture sites in the pediatric population were the distal forearm and distal arm, whereas hand, distal forearm, and foot were most common fracture sites in adults, in both pandemic and non-pandemic periods. The proportional increase in femoral and tibial shaft fractures in group 1, and toe, tibial shaft, and metacarpal fractures in group 2 was found to be statistically significantly (p<0.05). In group 1; 6.8%, 7.7%, and 14.6% of the fractures were treated surgically in 2018, 2019, and 2020, respectively (p<0.001). For group 2, these rates were 20.1%, 18.6%, and 18.1%, respectively (p=0.67). There were 48, 29, and 26 open fractures in 2018, 2019 and 2020, respectively (p=0.066). In pandemic period, duration of the hospital stay was significantly shorter for distal humerus and proximal femur fractures (p values= 0.001 and 0.017, respectively).

CONCLUSION

We observed that the frequency of fractures decreased by approximately one-third during the pandemic period compared with that in the non-pandemic period. The mean age of the patients with a fracture in the pediatric group was found to have decreased also. Finger fractures in pediatric patients and metatarsal fractures in adult patients were found to have significantly decreased during the pandemic.

LEVEL OF EVIDENCE

Level III, Diagnostic study.

Quantitative assessment of changes in lesser trochanter shapes in relation to femoral rotations

OBJECTIVE

The aim of this study was to evaluate changes in lesser trochanter shapes in relation to femoral rotations and to develop a reference value for the determination of clinically relevant malrotation of the femur.

METHODS

Patients who underwent computed tomography angiography between January 2009 and July 2018 were identified based on a review of their institutional medical records. Thereafter, three-dimensional (3D) images of the whole femur for a total of 860 patients were obtained from their tomographic sections. The distance between the lateral outer cortex of the femur and the most medial point of the lesser trochanter with the femur in neutral rotation was measured and set as the reference value. Then, the same distance was measured at 5°, 10°, 15°, and 20° of femoral internal rotation and at 5°, 10°, 15°, 20°, and 25° of femoral external rotation. To avoid magnification errors, the reference values were divided by each measured value at these different rotation angles and then multiplied by 100.

RESULTS

The mean distances between the lateral cortex and the most medial point of the lesser trochanter at 5°, 10°, 15°, and 20° of femoral internal rotation were 97%, 93%, 90%, and 88%, respectively, of those measured with the femur in neutral rotation. The same distances at 5°, 10°, 15°, 20°, and 25° of femoral external rotation were 102%, 104%, 106%, 107%, and 108%, respectively, of those measured with the femur in neutral rotation. There was no statistically significant difference between the measured distances in males and females (p>0.05). However, significant differences were observed among each measured distance at different angles of femoral rotation (p<0.01).

CONCLUSION

The surgeon should be aware of the possible femoral malrotation if the distance between the lateral cortex of the femur and the most medial point of the lesser trochanter on the operated side is more than 106% or less than 90% of that measured with the femur in neutral rotation on the healthy side.

LEVEL OF EVIDENCE

Level IV, Diagnostic study.

A New Reference to Evaluate Syndesmosis in Sagittal Plane Radiographs of the Ankle: The Lateral Posterior Ankle Ratio

BACKGROUND

Confirmation of anatomical reduction of ankle syndesmosis is mandatory because improper reduction leads to poor functional results. Coronal plane evaluation of syndesmosis is well described in the literature, but there is little information about sagittal plane evaluation. We sought to evaluate the relationship of fibula and tibia in the sagittal plane and create a new reference that can be applied easily and reliably.

METHODS

Lateral ankle radiographs of 337 individuals with no history of ankle fracture were evaluated. A line was drawn between the anterior and posterior cortices of the distal lateral tibia, and the length of this line was measured (line 1). The distance between the anterior and posterior cortices of the fibula on this line was measured, and the center of this second distance was identified and marked. The posterior half of the fibular width was divided by line 1 and was named the lateral posterior ankle ratio (LPAR). Statistical analysis was performed by side and sex.

RESULTS

Mean patient age was 38.6 years; mean LPAR was 0.48. There was a significant difference between men and women by age (P < .001) and LPAR (P = .01). There was no significant difference between right and left ankles by age (P = .63) and LPAR (P = .64). The LPAR was less than 0.40 in 6.8% of the radiographs, 0.40 to 0.50 in 57.9%, and greater than 0.50 to 0.60 in 32.9%.

CONCLUSIONS

The LPAR should approximate 50% in normal lateral ankle images and, by extrapolation, after syndesmotic reduction.

Preoperative planning of femoral head reduction osteotomy using 3D printing model: A report of two cases

The deformed and enlarged femoral head secondary to hip diseases such as Legg Calve Perthes and Developmental Dysplasia usually causes impingement between the aspherical head and the acetabulum. To restore and reduce the size of enlarged femoral head, a femoral head reduction technique has been described previously. The goal is to obtain a spherical femoral head and to cover the gliding surface with best available cartilage. Planning of osteotomy to achieve spherical head is the crucial point of surgery. It is usually done intra-operatively and dependent on experience of surgeon. Preoperative 3- Dimension (D) modeling of femoral head is commonly preferred to minimize this risk. In this technical note, preoperative planning with 3-D printing was demonstrated in two separate patients with Legg-Calve-Perthes Disease and developmental hip dysplasia. Surgical time was approximately 150 and 120 min, respectively. Blood loss was 230 and 300 cc, respectively. Patients were followed up 9 months and 12 months, respectively. None of the patients in this study developed avascular necrosis; however, the follow-up period is very limited. Moreover, none of the patients developed post-operative complications or required additional surgery. With a more detailed preoperative planning done on computer model and printed in 3-D, one can mimic the surgical procedure before the procedure. Finally, this technique is advantageous both for the patient and surgeon.

How are clinical outcomes related to the deviation severity of the tibiofemoral mechanical axis on coronal plane following knee arthroplasty?

OBJECTIVE

To analyze the effect of tibiofemoral mechanical axis (TFMA) deviation severity on clinical outcomes after total knee arthroplasty (TKA).

METHODS

We retrospectively reviewed the patients who underwent primary TKA between January 2002 and December 2010. After applying inclusion/exclusion criteria, we evaluated 70 knees of 51 patients. The mean ± SD follow-up period was 7.08 ± 1.34 years. The knees were divided into 3 groups based on TFMAs. The first group, identified as "well aligned," included the TFMAs that were neutral within 3° (0° ± 3°) of alignment. The second group, identified as "outliers 1," included the slightly deviated TFMAs (-3° to -6° valgus and +3° to +6° varus). The third group, identified as "outliers 2," included the severely deviated TFMAs of more than 6° from neutral alignment (<-6° valgus and > + 6° varus). The clinical outcomes of each group were compared by evaluating the Oxford Knee Score (OKS), visual analog scale (VAS), and Short Form-36 physical component summary (SF-36 PCS) and mental component summary (SF-36 MCS) scores.

RESULTS

We found that OKS, SF-36 PCS, and SF-36 MCS were nearly the same in the well-aligned and outliers 1 groups but worse in the outliers 2 group. VAS scores were nearly the same in all groups. (p > 0.05).

CONCLUSION

Function scores were impaired when the TFMA deviated more than 6° from neutral. However, the differences in clinical outcomes between well-aligned knees and those of outliers were not found to be statistically significant in the medium term.

Conservative Follow-up of Severely Displaced Distal Radial Metaphyseal Fractures in Children

Introduction

Distal radius fractures are the most frequent fractures seen in pediatric population and usually treated with closed reduction and casting. However, there is a risk of reduction loss and/or angulations in distal radial metaphyseal fractures. The purpose of this study is to evaluate the radiological and functional results of pediatric patients with distal radius metaphyseal fractures in which excessive displacement and/or angulations were accepted and to question upper acceptable limits in light of current literature.

Methods

Patients between five and 15 years of age with displaced distal radius fractures who were treated conservatively with significant angulation or translation were included in this study. Patients’ demographic data were gathered from hospital’s digital database. Clinical and radiological evaluations of all patients were done prospectively based on the last outpatient clinic control. Range of motion of wrist and elbow joint was measured with a goniometry, neurovascular status was documented, muscle strength was assessed and finally existing deformity measurements were performed clinically. Radiological evaluation was performed on pre-reduction, post-reduction, cast removal, 6th and 12th months and final examination radiographs. All measured values were compared with uninjured side. Radiologically, the percentage of translation, the amount of angulations, the distance from the fracture to the epiphyseal line, and the radius lengths were measured. Radial inclination and palmar tilt angles as well as ulnar variance and residual angulation were measured in both antero-posterior (AP) and lateral forearm radiographs. The Mann–Whitney U test was used to compare the variables in SPSS version 21. p < 0.05 was considered statistically significant.

Results

Twenty-nine patients with a mean age of 8.8 ± 3.1 years were included in this study. The mean follow-up duration was 17.4 ± 6.7 months. Compared to the uninjured side, in 24 (83%) patients, there were no limitations on wrist movements except five patients in forearm pronation clinically. In patients with re-displacement, the mean displacement occurrence time was 13.3 ± 4.9 (7–21) days. The translational and/or angulations in AP and lateral radiographs fully remodeled at the end of 6th month.

Conclusion

This study demonstrates that radial and dorsal angular deformities up to 39° and 22° volar angulation and complete displacement correct fully in children up to 10 years old. In children between 10 and 15 years, the dorsal angulation up to 38°, radial angulation up to 23°, and volar angulation up to 16° are acceptable for remodeling capacity of the child.

Analysis of the factors causing tight cast syndrome after closed reduction and casting of pediatric distal radius fractures

Objective

The aim of this study was to evaluate the most important factors which can cause “tight cast syndrome’’ (TCS) in pediatric patients with distal radius fractures.

Methods

Patients, who were at or under 15 years old and treated conservatively with an diagnosis of distal radius fracture between August 2015 and August 2017 were included in to the study. Fifty four patients, who had been found to experience TCS were accepted as group 1 and sixty-two patients without TCS as group 2. Cast index, pre-/post reduction translation, pre-/post reduction angulation, localization and displacement of the fracture, need for re-manipulation, and presence of associated distal ulna fracture were evaluated for both groups. Statistical analysis was performed to evaluate cut off value for cast index values for both TCS and loss of reduction and logistic regression analysis of the other possible factors.

Results

Pre-/post-reduction translation (over 50% and 10%, respectively) (odds ratios:0.167 and 0.524, respectively), a cast index value below than 0.775 (odds ratio:3.080), displaced type fracture (odds ratio:8.028), presence of re-manipulation (odds ratio:0.131) and associated distal ulna fracture (odds ratio:2.029) were found to be statistically significantly important for the occurrence of TCS. The most important factors were decreased cast index value and presence of initially displaced type fracture. Loss of reduction (LOR) risk was found to be increased in patients with a cast index value of greater than 0.875.

Conclusion

One should be very careful when following a pediatric patient who have a displaced distal radius fracture which has initial/post reduction translation in AP plane, which is associated with distal ulna fracture, which required re-manipulation and most importantly which cast index is under than 0.775 in terms of occurrence of TCS. We recommend obtaining a cast index value between 0.775 and 0.875 to prevent both TCS and LOR.

Level of evidence

Level III, Therapeutic study.

The Influence of Resident Level of Training on Fluoroscopy Time in Pediatric Supracondylar Humeral Fractures Treated with Closed Reduction and Percutaneous Pinning

Objective The purpose of this study was to evaluate the effect of resident level of training on fluoroscopy duration in pediatric supracondylar humeral fractures treated with closed reduction and percutaneous pinning (CRPP). Methods After classifying the surgeons according to their seniorities, the duration of fluoroscopy time of 80 patients with extension type III supracondylar fractures during reduction and pinning was recorded. Results The time duration of reduction procedures was similar in all groups with respect to the surgical experience; however, time durations of percutaneous pinning procedures were found statistically different between groups (p=0.042). Conclusion Surgical experience is very important in the management of supracondylar humeral fractures in children, especially in percutaneous pinning rather than closed reduction.

Do Patients With Acute Isolated Pubic Ramus Fractures Have To Be Hospitalized?

A total of 129 patients were included in the study. Haemoglobin levels on admission and at 24 hours were evaluated. Radiographs and computed tomography of the pelvis were also evaluated. The patients were divided into subgroups, according to the accompanying occult posterior pelvic injuries, whether they received anticoagulant-antiaggregant treatment, the number of pubic ramus fractures (single or multiple), the level of energy (low or high) and the zone(s) of the fracture(s). The mean haemoglobin decrease was 1.21 g/dL. Forty-six of the patients were under anticoagulant or antiaggregant treatment. Fifty-one of the fractures occurred due to low energy trauma. Posterior ring injuries were observed in 75 of the patients. Haemoglobin level decreases were statistically significant in injuries with high energy trauma aetiology, in patients using antiaggregant or anticoagulant and in fractures of the lateral half of the superior pubic ramus. It is important to follow all pubic ramus fractures closely because, even in low energy trauma, haemoglobin levels could decrease significantly. We recommend hospitalization to monitor this group of patients.

How safe is the semi-sterile technique in the percutaneous pinning of supracondylar humerus fractures?

BACKGROUND

The purpose of the present study was to evaluate safety and efficiency of the semi-sterile technique used in recent years in treatment of pediatric supracondylar humeral fractures (SHF).

METHODS

Total of 712 patients who were treated for SHF via closed reduction and percutaneous fixation with semi-sterile technique were enrolled in present study. Patients were evaluated for postoperative infection and other complications. Clinical and radiological assessments were also made.

RESULTS

It was found that there were 52 (7.3%) pin tract infections, which responded to oral antibiotic administration and pin care without need for early pin removal (before 3 weeks). There were no deep infections. Loss of reduction was observed in 82 patients (11.5%). There were 59 iatrogenic nerve injuries (8.3%), of which 52 (7.3%) were ulnar palsy. Clinically apparent cubitus varus was observed in 29 (4.1%) patients.

CONCLUSION

Though semi-sterile technique is an effective treatment in closed percutaneous pinning of SHF, increased pin tract infection risk is a matter of concern.

Intraarticular Giant Size Angiolipoma of the Knee Causing Lateral Patellar Dislocation

BACKGROUND

Angiolipomas are benign tumors usually seen in patients during their 2^nd and 3^rd 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.

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.

Which factor is most important for occurrence of cutout complications in patients treated with proximal femoral nail antirotation? Retrospective analysis of 298 patients

INTRODUCTION

Mechanical complications, such as cut-out of the head-neck fixation device, are the most common causes of morbidity after trochanteric femur fracture treatment. The causes of cut-out complications are well defined in patients who are treated with sliding hip screws and biaxial cephalomedullary nails but there are few reports about the patients who are treated with proximal femoral nail antirotation.

AIM

The purpose of this study was to evaluate the most important factor about occurance of cutout complication and also to evaluate the risks of the combination of each possible factors.

PATIENTS AND METHODS

Overally 298 patients were enrolled in the study. Medical records were reviewed for patients' age, fracture type, gender, anesthesia type and occurance of cut-out complication. Postoperatively taken radiographs were reviewed for tip-apex distance, obtained collo-diaphyseal angle, the quadrant of the helical blade and Ikuta reduction subgroup. The most important factor (s) and also predicted probability of cut-out complication was calculated for each combination of factors.

RESULTS

Cut-out complication was observed in 14 patients (4.7 %). The most important factor about occurrence of the cut-out complication was found as varus reduction (p: 0.01), the second important factor was found as implantation of the helical blade in the improper quadrant (p: 0.02). Tip-apex distance was found as third important factor (p: 0.10). The predicted probability of cut-out complication was calculated as 45.6 % when whole of the four surgeon dependent factors were improperly obtained.

CONCLUSION

Althought obtaining proper tip-apex distance is important to prevent cutout complication in these fractures, if the fracture is not reduced in varus position and helical blade is inserted in the proper quadrant, possibility of cut-out complication is very low even in the patients with high tip-apex distance.

Fixation of intertrochanteric femur fractures using Proximal Femoral Nail Antirotation (PFNA) in the lateral decubitus position without a traction table

OBJECTIVE

The aim of this study was to evaluate whether intertrochanteric femur fractures can be reduced and nailed properly in the lateral decubitus position using Proximal Femoral Nail Antirotation (PFNA) as a fixation device without the use of a traction table.

METHODS

The study included 207 patients (81 male and 126 female; mean age: 75 years, range: 22 to 95 years). According to the Evans classification, there were 7 Type 1, 40 Type 2, 33 Type 3, 38 Type 4, 61 Type 5 and 28 reverse oblique fractures. Radiographs were used to measure the tip-apex distance (TAD), the quadrant of the helical blade according to Cleveland and Bosworth, Ikuta's reduction subgroup, collodiaphyseal angle and reduction gaps postoperatively.

RESULTS

Mean follow-up time was 20.4 (range: 6 to 38) months. According to Ikuta's classification, 176 (85%) reduced fractures were of subtype N, 15 (7.2%) subtype P and 16 (7.7%) subtype A. Good or acceptable reduction according to the Herman criteria was obtained in 99% of fractures. Mean TAD was 29.2 millimeters. Mean operation time was 57.2 minutes. Optimal blade position (center-center or inferior-center) was achieved in 53.5% of patients and was in the superior-posterior quadrants in only 2.4% of patients. Cut-out complication occurred in 9 patients (4.3%).

CONCLUSION

While the nailing of intertrochanteric fractures in a lateral decubitus position does not provide ideal quadrant placement and TAD, results are encouraging probably due to the excellent stability that is provided by PFNA.

How are outcomes affected by performing a one-stage combined procedure simultaneously in bilateral developmental hip dysplasia?

PURPOSE

The aim of this study was to compare the outcomes of one-stage combined surgical treatment in children of unilateral and bilateral developmental hip dysplasia diagnosed after walking age.

METHODS

We reviewed 24 patients who underwent one-stage combined surgery for DDH diagnosed after walking age. Group I consisted of 12 patients with bilateral disease who underwent bilateral operation at one operative setting. Group II consisted of 12 patients with unilateral disease. Pre-operatively the hips were classified according to Tönnis classification. Acetabular dysplasia was evaluated by measuring acetabular index (AI) angles pre-operatively. The acetabular improvements with time regarding AI was noted immediately postoperatively, every six months, and at the final follow-up examination.

RESULTS

Mean follow up of the bilateral group I and group II were 54.8 months (range 20-84 months) and 52.6 months (24-80), respectively. There were no statistically significant differences between immediate postoperative and final follow up acetabular index improvement rates in both groups. Also there was no significant difference when both hips were compared in group I. The clinical final outcome of both groups and within group I was similar.

CONCLUSIONS

Simultaneous combined surgery is a challenging but worthwhile procedure for late diagnosed patients with bilateral DDH. The short-mid term outcomes of the procedure are encouraging.