Abdullah Gogus

The role of posterior instrumentation and fusion after anterior radical debridement and fusion in the surgical treatment of spinal tuberculosis: experience of 127 cases.

Long periods of immobilization, progressive kyphosis and graft failure are the major postoperative problems encountered after anterior radical surgical treatment for tuberculosis of the spine. Posterior fusion and instrumentation can be an effective solution for these problems. Effectiveness of posterior fusion and instrumentation was investigated in this study on the basis of the cases with anterior procedure only, and with combined anterior–posterior procedures. One hundred twenty-seven cases of tuberculosis of the spine were surgically treated between 1987 and 1995. All had either 1 or more of conditions such as spinal cord compression and neurological deficit, vertebral body collapse and kyphosis, or wide paravertebral abscess unresponsive to medical treatment. Of these, 57 had only anterior radical procedure between the years 1987 and 1993. Seventy cases had posterior instrumentation and fusion after the anterior procedure between the years 1991 and 1995. In about two third of the patients (81) autogenous iliac strut graft and in one third of them (40) autogenous fibular strut graft (cases with more than 2 level involvement) was used along with rib grafts after debridement. Twenty-one of the 57 patients who had only anterior procedure demonstrated a postoperative increase of kyphosis of more than 10 degrees. Increased kyphosis was due to graft slippage in 3, resorption in 2 and subsidence in 16 patients. No such increase or graft failure was noted in cases of combined anterior–posterior procedure. The difference in terms of kyphosis was found to be statistically significant (P=0.047). Anterior radical debridement and strut graft is the golden standard in the surgical treatment of spinal tuberculosis, but it should always be accompanied by posterior instrumentation and fusion to shorten the immobilization period and hospital stay, obtain good and long lasting correction of kyphosis, and prevent further collapse and graft failure.

Complications encountered in proximal humerus fractures treated with locking plate fixation

OBJECTIVES We evaluated the complications encountered following locking plate fixation of proximal humerus fractures. METHODS The study included 103 patients (70 females, 33 males; mean age 62 years; range 21 to 90 years) who were treated with open reduction and locking plate fixation for proximal humerus fractures between September 2005 and April 2009. Fixation was performed using the PHILOS locking plate in 93 patients, and S3 humerus plate in 10 patients. Postoperatively, a shoulder-arm sling was applied for six weeks and a standard rehabilitation program was used in all the patients. Intraoperative, acute postoperative, and late postoperative complications were assessed on radiographs. Varus inclination was defined as less than 120 degrees of the inclination angle on immediate postoperative radiographs, and varus displacement as postoperative increases in the varus angle. The mean follow-up period was 19 months (range 2 weeks to 43 months). RESULTS Complications were seen in 10 patients (9.7%; mean age 67 years). The PHILOS plate was used in nine patients and S3 plate was used in one patient. Five patients (4.9%) had varus inclination with a mean inclination angle of 112.6 degrees (range 105 degrees to 118 degrees), four patients (3.9%) developed varus displacement with a mean inclination angle of 102.5 degrees (range 95 degrees to 110 degrees), and intra-articular screw penetration was seen in five patients (4.9%). The remaining complications were fixation failure (n=1, 1%), implant fracture (n=1), and deep infection (n=1). Screw penetration exceeded 3 mm in three patients, requiring revision surgery. The mean ages of patients with varus inclination, varus displacement, and screw penetration were 76.6, 74.4, and 71 years, respectively. Three patients with varus inclination (60%) developed varus displacement. Screw penetration was observed in three patients (60%) with varus inclination, and in all patients with varus displacement. The mean Constant-Murley shoulder score was 67.8 (range 50 to 90) in patients who developed a complication. CONCLUSION Our findings show that locking plate and screw systems represent a significant treatment option in the treatment of comminuted and displaced humerus fractures, with low complication rates. Accurate indication, protection of the heads inclination angle through appropriate surgical approach and proper technique, and fine calculation of screw length are essential for successful functional results.

Magnetic resonance imaging of tuberculous spondylitis.

The clinical and imaging findings of patients with a confirmed diagnosis of tuberculous spondylitis were retrospectively analyzed to assess the diagnostic value of magnetic resonance imaging (MRI) and determine the different patterns of spine involvement. Fifty-three patients with plain radiographs and MRI of the entire spinal column were included in the study. Sagittal T1- and T2-weighted MRIs of the entire spine and axial T1- and T2-weighted MRIs at the levels of interest were retrospectively evaluated. Plain radiographic correlation was obtained in all patients. The lower thoracic and thoracolumbar spine was the most commonly involved region. Magnetic resonance imaging is effective in the early diagnosis of tuberculous spondylitis. It also detects lesions, which may not be apparent on plain radiographs.

Avascular necrosis of the femoral head after hip arthroscopy.

We report a case of a 61-year-old woman who underwent hip arthroscopy for a labral tear. The acetabular labrum was resected arthroscopically. Three months later, magnetic resonance imaging showed avascular necrosis of the femoral head. Theoretically, avascular necrosis following hip arthroscopy may result from traction on vessels supplying the femoral head, direct injury to such vessels during portal entrance, raised intra-articular pressure, prolonged operating time and damage to vessels during bony resection or osteochondroplasty for femoroacetabular impingement. We presume that avascular necrosis in our case was a result of a traction injury and increased intra-articular pressure.

Effect of diclofenac sodium on union of tibial fractures in rats

Nonsteroidal anti-inflammatory drugs are often used for 7 to 10 days after fracture because of their effects on bone metabolism. This study evaluated the effect of diclofenac sodium, administered at clinical dosage and duration, on bone union. Fifty-four male Wistar rats were randomly and equally divided into three groups: control, diclofenac 1 mg, and diclofenac 2 mg. Closed diaphyseal fractures were induced in the right tibias of all rats; the two diclofenac groups received intramuscular injections in the contralateral hips for 10 days. All animals were immobilized in circular casts on the upper thighs. Six rats in each group were sacrificed at weeks 2, 4, and 6, and bony union was evaluated clinically, radiologically, and histologically. At the end of 2 weeks, clinical examinations showed subjective differences between the two treated groups and control animals, with more stable callus formation in controls. Radiologic evaluation of the callus showed numeric, but not significant, differences between control and treated animals. At 4 and 6 weeks, clinical and radiologic findings were comparable among groups. Histologically, no significant differences in callus formation were evident at any evaluation.

The results of internal fixation of proximal humeral fractures with the PHILOS locking plate

OBJECTIVES Proximal and diaphyseal humeral fractures are common especially in the elderly, presenting as a challenging problem due to their high complication rates following surgical treatment. In this prospective study, we evaluated the results of patients treated with the PHILOS (Proximal Humeral Internal Locking System) locking plate, a new technique recently developed by the AO/ASIF. METHODS Forty-one patients who were treated with the PHILOS plate for proximal humeral fractures were evaluated in two age groups. Group A included 24 patients (12 males, 12 females; mean age 47 years; range 24 to 64 years) younger than 65 years, and group B involved 17 patients (4 males, 13 females; mean age 78 years; range 67 to 90 years) at or above 65 years. Radiographically, all fractures were classified according to the AO/ASIF system. Surgery was performed with the deltopectoral approach in 10 and two patients, and with a deltoid split in 14 and 15 patients in group A and B, respectively. Functional and radiographic results were evaluated after a mean follow-up of 15 months (range 6 to 28 months). RESULTS The mean Constant scores were 95.0 (range 74 to 100) and 92.8 (range 72 to 100) in group A and B, respectively (p>0.05). After six months of surgery, Constant scores and functional outcomes were similar in patients operated on with the deltopectoral approach or deltoid split. There was neither nonunion nor implant failure. Complications included intra-articular screw penetration (n=1), displacement of the greater tuberculum (n=1) with oblique placement of the plate (n=1), insufficient reduction (n=4), and varus displacement of the humeral head (n=3). No avascular necrosis was seen. CONCLUSION Locking plate system is superior over other means of fixation methods, particularly in osteoporotic fractures, because it allows early rehabilitation and does not result in implant failure.

Surgical treatment of elbow dislocations accompanied by coronoid fractures

OBJECTIVES We evaluated the results of surgical treatment for elbow dislocations accompanied by Regan-Morrey type 2-3 coronoid fractures. METHODS Eight patients (6 males, 2 females; mean age 44 years; range 23 to 76 years) underwent surgical treatment for elbow dislocations accompanied by a coronoid fracture. Three patients had Regan-Morrey type 2, five patients had type 3 coronoid fractures. Accompanying injuries were Mason-Johnston type 4 radial head fractures (n=6), olecranon fractures (n=4), lateral humeral condyle fracture (n=1), and lateral (n=5) or medial (n=2) collateral ligament ruptures. Coronoid fractures were fixed with a plate, screw, or a cerclage wire in all the patients except for one patient who underwent coronoid excision. For radial head fractures, plate or screw and K-wire fixation was performed in two patients and radial head prosthesis was used in four patients. Olecranon fractures were fixed with a plate or AO tension band. Functional results were assessed using the Mayo elbow performance score. The mean follow-up period was 22.6 months (range 1 to 65.5 months). RESULTS Union was achieved in all the patients. At the latest assessments, the mean Mayo elbow performance score was 84.3 (range 50 to 100). All the patients expressed satisfaction with surgical treatment except for one patient who underwent coronoid excision. All the fixation materials used for olecranon fractures were removed after union due to implant-associated pain. Ulnar nerve transposition was required in two patients with fractures involving the anteromedial facet of the coronoid process. Two patients developed heterotopic ossification that did not affect the range of motion of the elbow. CONCLUSION Surgical treatment of elbow dislocations associated with Regan-Morrey type 2-3 coronoid fractures enables a concentric reduction of the elbow, stability, and early motion.

Outcomes of trochanteric femoral fractures treated with proximal femoral nail: an analysis of 100 consecutive cases

Purpose In this study, we aimed to report the results of a retrospective study carried out at our institute regarding cases of patients who had suffered proximal femoral fractures between January 2002 and February 2007, and who were treated with a proximal femoral nail. Materials and methods One hundred consecutive cases were included in the study. A case documentation form was used to obtain intraoperative data including age, sex, mechanism of injury, type of fracture according to Association for Osteosynthesis/Association for the Study of Internal Fixation (AO/ASIF) classification and the American Society of Anesthesiologists’ (ASA) physical status classification (ASA grade). Clinical and radiographic examinations were performed at the time of admission and at the 6th week; subsequent visits were organized on the 3rd month, 6th month, and 12th month, and in patients with longer follow-up and annually postoperatively. The Harris score of hip function was used, and any change in the position of the implants and the progress of the fracture union, which was determined radiologically, was noted. Results The mean age of the patients was 77.66 years (range: 37–98 years), and the sex distribution was 32 males and 68 females. Seventy-three fractures were reduced by closed means, whereas 27 needed limited open reduction. The mean follow-up time for the study group was 31.3 months (range: 12–75 months). Postoperative radiographs showed a near-anatomical fracture reduction in 78% of patients. The Harris hip score was negatively correlated with the ASA score and patient age. No cases of implant failure were observed. Three patients died before discharge (one due to pulmonary embolism, two due to cardiac arrest), and five patients died due to unrelated medical conditions within the first 3 months of the follow-up. Conclusion Our study showed that proximal femoral nail is a reliable fixation with good fracture union, and it is not associated with major complications in any type of trochanteric femoral fracture.