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Hip involvement is one of the most common skeletal manifestations of hereditary multiple exostoses (HME) in 30-90% of the patients. The anatomical changes in the proximal femur in patients with HME, may lead to deformities and related functional deficits. Its effect on the range of motion (ROM) of the hip joint is not well described. The aim of this study was to evaluate the role of hip deformity of HME disease in the ROM of the hip joint. It was hypothesized that certain morphological parameters affect the ROM of the hip joint. Conclusively, 44 patients including 27 men and 17 women (88 hips) were evaluated. Hips are divided in Group 1 (no ROM limitation group) and Group 2 (ROM limitation group). The head-neck ratio (HNR), center edge angle (CE), Sharp's acetabular angle (SAA), alpha angle (AA), neck shaft angle (NSA) and ROM parameters were measured. The correlations between radiological parameters (SAA, CE, NSA, AA and HNR), and the ROM data (F, E, Abd, Add, IR and ER) were statistically evaluated. All evaluated parameters (SAA, CE, NSA, AA) except the HNR do not show significant differences between study group 1 (no ROM limitation group) and group 2 (ROM limitation group). The means of the HNR in group 1 were significantly higher than those in group 2 (HNR: 1.23 vs. 0.92, p<0.001). In group 2 HNR showed a strong positive correlation with Abd (PC 0.72, p<0.001), E (PC 0.7, p<0.001), ER (PC 0.67, p<0.001), IR (PC 0.67, p<0.001) and F (PC 0.66, p<0.001). HME patients with hip involvement have better ROM of the hip joint, if they have the higher HNR. Additionally, a positive correlation between HNR and ROM capacity was determined. [ABSTRACT FROM AUTHOR]

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Unicameral bone cysts (UBC) are reported to be the underlying lesion in 40% of pathological femoral neck fractures in skeletally immature patients. They are typically asymptomatic and incidentally found on imaging. However, when symptomatic, it commonly may present with pathologic fracture that causes pain, swelling, or deformity. The purpose of this study was to assess the natural history of the pediatric proximal femoral unicameral bone cyst, risk factors for pathological fracture and recurrence. Medical records were retrospectively reviewed of patients with pediatric proximal femoral UBC’s who underwent surgery between 2004 and 2018. We included 51 consecutive patients with pediatric proximal femoral UBC (36 impending fractures/15 pathological fractures). The patients were evaluated regarding the localization of the UBC and the activity of the cyst. The cyst parameters were measured, and the patients were further assessed regarding the presence of pathological fracture and applied treatment. The pathological fracture group was compared to the impending fracture group using radiological cyst parameters, management options, healing, recurrences, and other related complications. The most commonly affected localizations were combined involvement of femoral neck and intertrochanteric (n=21) The number of latent lesions was 27 and active lesions were 24. The mean cyst index in our series was 3.8±1.2 (1.2-7.2). The cyst index in our series was correlated with pathological fractures. (p=0.048) There were significantly higher cyst index values in recurrent cases. (p=0.016) The cyst extension below the trochanter minor level was found as a risk factor for pathological fractures. (p=0.021) The most common treatment in our series was curettage, graft packing, and plate fixation with 27 patients. The treatment method showed no correlation with consolidation or recurrence rate. According to the healing criteria for UBC’s at final follow-up, 36 cysts were completely consolidated, 13 were evaluated as incomplete healing and two were persistent. The recurrence rate was significantly high in UBC’s who were operated on at <10 years of age (p=0.006). Accordingly, the active lesions were also significantly related to earlier recurrence (p=0.03). Although younger age, active cysts, and higher cyst index are shown as risk factors for recurrence, not for fracture in proximal femoral UBC’s. However, with age, the cyst relatively migrates to the weight-bearing intertrochanteric area, which may inevitably impose a major risk for pathological fractures. Ensuring stability with a plate even in impending fractures of the proximal femur may aid early mobilization and faster recovery. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective diagnostic study. Purpose: To define a new radiological sign, "Baltalimani sign," in severe angular kyphosis (SAK) and to report its relationship with the risk of neurological deficits and deformity severity. Overview of Literature: Baltalimani sign was previously undefined in the literature. Methods: We propose Baltalimani sign as the axial orientation of the vertebrae that are located above or below the apex of angular kyphosis on anteroposterior radiographs. Patients with SAK of various etiologies with kyphotic angles =90° were selected and evaluated for the presence of Baltalimani sign. Demographic data of the patients including age, gender, etiology, neurological status, local kyphosis angles, and the location of the kyphosis apex were recorded. Sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPV) of Baltalimani sign for the risk of the neurological deficits were evaluated by the IBM SPSS ver. 20.0. A p -values of <0.05 were considered statistically significant. Cohen's kappa was used for analysis of interrater agreement. Results: The mean local kyphosis angle in all patients was 124.2° (range, 90°-169°), and 15 of 40 (37.5%) patients had neurological deficits. Baltalimani sign was seen in 13 of 15 patients with neurological deficits (p =0.001). Baltalimani sign showed a sensitivity and specificity PPV and NPV of 61.9%, 86.7%, 89.5%, and 68.8% for the risk of the neurological deficits in SAK patients, respectively. Cohen's kappa value was moderate (κ=0.506). Conclusions: The detection of Baltalimani sign in SAK may indicate severity of deformity and the risk of neurological deficits. [ABSTRACT FROM AUTHOR]

Aneurysmal bone cyst originating from the surface of the bone, either within the cortex or subperiosteally, is an uncommon anatomic subtype. This article reports the clinical and radiologic evaluations and treatment outcomes of 10 patients with surface aneurysmal bone cysts that were surgically treated between 1982 and 2014. Mean age at the time of surgery was 22.4 years (range, 11-44 years). According to Capanna's radiographic evaluation criteria, 6 of the lesions were classified as type V and 4 were classified as type IV. Radiographically, periosteal shell formation was observed to be complete in 4 patients, partial in 3, and absent in 3, and 6 patients had Codman's angle or buttress formation. In 1 patient, computed tomography scan showed birdcage-like ossification attached to the surface of bone. Magnetic resonance imaging showed fluid-fluid levels in 5 patients. All of the patients had standard curettage and high-speed burr application as an adjuvant. No patient had local recurrence at the end of the follow-up period of 98.4 months (range, 13-288 months). These findings show the importance of careful radiologic evaluation and biopsy to better plan a treatment strategy when surface aneurysmal bone cyst is included in the differential diagnosis. The finding of fluid-fluid levels on magnetic resonance imaging or computed tomography is not pathognomonic for primary aneurysmal bone cyst; however, the absence of this finding does not rule out the diagnosis. The rate of local recurrence after curettage plus high-speed burr is reasonably low, and other adjuvant procedures should be used whenever needed. [Orthopedics. 2016; 39(5):e897-e903.]. [ABSTRACT FROM AUTHOR]

Introduction Quadriceps tendon injuries are rare. There is a limited number of studies in the literature, reporting partial quadriceps tendon ruptures. We did not find any study reporting an isolated vastus intermedius tendon injury in the literature. Presentation of case A 22 years old professional rugby player with the complaints of pain in the right lower limb, decreased range of motion in right knee and a mass in the mid-anterior of the right thigh applied following an overloading on his hyperflexed knee during a rugby match. T2 sequence magnetic resonance images revealed discontinuity in the vastus intermedius tendon and intramuscular hematoma. The patient has been conservatively treated. Discussion Quadriceps tendon ruptures generally occur after the 4th decade in the presence of degenerative changes. Our case is a young professional rugby player. Isolated vastus intermedius tendon rupture is unusual. Conservative treatment is performed as the intermedius tendon is in the deepest layer of the quadriceps muscle. Conclusion We report the first case of isolated rupture of the vastus intermedius tendon in the literature and we claim that disorder may be succesfully treated with conservative treatment and adequate physiotheraphy. [ABSTRACT FROM AUTHOR]

Background: Minimally invasive percutaneous plate osteosynthesis (MIPO) and intramedullary nailing (IMN) are the two most commonly used methods for distal tibial extra-articular fractures; however, the ideal treatment is still on debate. The aim of this study was to compare MIPO and IMN in the treatment of distal tibial extra-articular fractures in terms of cost analysis according to health insurance records in Turkey., Methods: The data of patients who underwent either MIPO or IMN for the treatment of distal tibial extra-articular fractures between 2013 and 2018 were analyzed in this retrospective study. Patients' clinical data, as well as the overall expenses from the first admission until return to work including hospitalization, and all outpatient controls had been reviewed from the hospital's billing department. The total amount of money paid per month by Turkish National Social Security Institution to the patient until the patient's returns to work were also recorded., Results: 118 consecutive patients (35 female-83 male) with the mean age of 37.2±13.4 were participated to the study. IMN group consisted of 57 patients with a mean age of 36.7±12.8 years, and MIPO group consisted of 61 patients with a mean age of 37.8±13.6 years. No significant differences were observed between study groups in terms patients' age, gender, fracture classification (AO/OTA: Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association), soft-tissue injury (Tscherne classification), presence of type 1 open fracture, and presence of accompanying fibula fracture. There was no statistical difference between two groups in terms of pre-operative hospital stay (p=0.713). However, the mean length of hospital stay was significantly higher in the MIPO group (p=<0.001). The means of number of total outpatient controls, time to union, and return to work were also significantly higher in the MIPO group (p=0.005, p<0.001 and p<0.001, respectively). The mean hospital cost until discharge and the mean total cost until return to work were significantly higher in the MIPO group (p=0.001 and 0.001, respectively). The mean total costs of hospital stay and outpatient controls were also significantly higher in the MIPO group (p=0.001 and 0.004, respectively). The mean implant costs did not significantly differ between groups (p=0.179)., Conclusion: According to the results acquired from the present study, IMN is a better option compared to MIPO for the treatment of extra-articular distal tibial fractures in terms of costs paid by the national health insurance in Turkey.

Objectives: This study aims to compare the clinical and radiological outcomes of the two fixation methods frequently used in the treatment of Schatzker type II fractures: lag screw fixation and lateral anatomic plate fixation., Patients and Methods: This retrospective study, which was conducted between January 2005 and December 2014, included 61 patients (41 males, 20 females; mean age 43.4±13.1 years; range, 20 to 76 years) with Schatzker type II (Orthopaedic Trauma Association (OTA)/Arbeitsgemeinschaft für Osteosynthesefragen (AO) 41-B3) fractures. Patients were divided into two groups according to the type of surgery as cannulated lag screw fixation group (group 1, n=24, 39.4%) and lateral locking plate fixation group (group 2, n=37, 60.6%). Intraoperative mediolateral and anteroposterior instability were measured. Final knee flexion- extension range of motion (ROM), single-leg hop test, Knee Society Score (KSS), Hospital for Special Surgery (HSS) and short form 36 (SF36) scores were obtained at the last follow-up., Results: The mean age of patients was 42.1±13.8 years in group 2 and 45.5±12.2 years in group 1. The mean follow-up period was 34±4 months. Minimal or no arthritis was detected in 75% (n=18) of patients in group 1 and 78% (n=29) of patients in group 2 (p=0.27). Single leg-hop test results (p=0.55), final follow-up knee ROM (p=0.40), KSS (p=0.21), HSS (p=0.15), and SF36 scores of group 1 were similar to group 2. In group 1, the duration of surgery was shorter (p<0.001) and the cost of treatment was lower (p<0.001)., Conclusion: Treatment of Schatzker type II tibial plateau fractures with lag screws seems to provide less invasive, cheaper, and faster surgical treatment as compared with lateral locking plate fixation. In addition, patients who underwent internal fixation with lag screws had similar clinical and radiological outcomes with those who underwent lateral locking plate fixation.

Objectives: This study aims to present our experience in the management of fractured femoral stems after primary and revision hip replacements by evaluating the clinical and radiographic characteristics and determining the effectiveness of the extraction methods., Patients and Methods: A total of 15 patients (5 males, 10 females; mean age 65.9 years; range, 49 to 87 years) who underwent revision hip replacement due to a fractured femoral stem between January 2005 and December 2019 were included in this retrospective study. The mechanisms and risk factors for failure as well as methods applied to extract fractured stem were analyzed through clinical and radiographic data., Results: Nine patients had fractured cemented femoral stems, while six patients had fractured fully porous coated cementless revision stems. Lack of proximal buttress in distally fixed femoral stems was detected in 11 patients and identified as the predominant mechanism resulting in fracture. The proximal extraction method with conventional revision instrumentation, the cortical window technique, and extended trochanteric osteotomy (ETO) were used in three, seven, and five cases, respectively., Conclusion: Our results demonstrated that the lack of proximal buttress is the most common reason for femoral stem fracture. Moreover, the proximal extraction method was mostly ineffective in fully porous femoral stems. A step-by-step approach should be considered for the extraction of a broken stem. The cortical window method can be considered as the second step if proximal extraction methods fail, and ETO should be considered at the last step if all techniques fail.

Tumor-to-tumor metastasis in the same bone is an extremely rare condition. Limited number of case reports exists for coincidence of benign and malign neoplasms but none for malignant to malignant metastasis. Occurrence of several individual malignancies in the same patient may eventually cause such coexistences. We report an Ollier's disease patient with malignant transformation to chondrosarcoma complicated by a pathologic fracture and eventually whose pathological examination revealed that the lesion was not only the chondrosarcoma but an accompanying metastasis from existing lung adenocarcinoma. This report includes clinical, radiological, histological diagnostic challenges in an unexpected lesion and a review of literature., (Copyright © 2018 Turkish Association of Orthopaedics and Traumatology. Production and hosting by Elsevier B.V. All rights reserved.)

Bizarre parosteal osteochondromatous proliferation (BPOP, also known as Nora's lesion) is a rare, benign, locally aggressive condition defined as osteochondromatous exostosis arising from the bony cortex. BPOP presents predominantly in the 2nd and 3rd decades of life, and commonly arises from the periosteum of metacarpals and metatarses, though rare locations have been reported, including the long bones, the maxillae, the bones of calvaria, and the sesamoids. The case of an osteochondromatous lesion in an infant with an intra-abdominal mass arising from the iliac wing, an atypical location of benign solitary lesions, is reported. Benign solitary lesions are exceptional in this age group. The parents of the patient, who was born in term at 3600 grams, discovered a mass in the left groin and observed decreased movement in the lower left extremity. No history of trauma was reported. When the patient was 5 months of age, AP pelvic X-ray, computed tomography, and magnetic resonance imaging revealed a bony mass displacing intra-abdominal organs anteromedially. Biopsy reported an osteocartilaginous lesion with calcified mature cartilaginous fragments surrounded by plasmacytoid, monotone, fibrinoid cells in myxoid background. Differential diagnosis included osteochondroma, osteochondromyxoma, BPOP, fibrocartilaginous mesenchymoma, chondromyxoid fibroma, periosteal chondroma, soft tissue chondroma, myositis ossificans, and juxtacortical chondroma. Biopsy of the resected specimen determined a diagnosis of BPOP. At 6-month postoperative follow-up, neither symptoms nor complaints related to the mass were present.

Unicameral bone cysts (UBC) and aneurysmal bone cysts (ABC) are benign cystic lesions of bone which are easily diagnosed. However, unusual locations may lead to a false diagnosis. Therefore the aim of this retrospective study was to determine the frequency of unusual localizations. The authors studied 451 cases with histopathologically confirmed diagnosis of UBC or ABC, seen between 1981 and 2012. In the UBC group (352 cases) humerus, femur and calcaneus were found to be the most common sites, while acetabulum, scapula, scaphoid, lunatum, metacarpals, metatarsals, toe phalanges and ulna each accounted for less than 1%. In the ABC group (99 cases) the most common sites of involvement were femur, humerus and tibia, while finger phalanges, ilium, acetabulum, pubis, calcaneus, cuboid, and toe phalanges each accounted for only 1%. The differential diagnosis of cystic bone lesions should include both UBC and ABC. Pain complaints plead for the latter, except in case of fracture.