Bilal Demir

Reconstruction of shoulder abduction and external rotation with latissimus dorsi and teres major transfer in obstetric brachial plexus palsy

Objectives: We evaluated the results of latissimus dorsi and teres major tendon transfer to the rotator cuff together with musculotendinous lengthening of the subscapularis and/or pectoralis major muscles in patients with internal rotation contracture and decreased external rotation and abduction secondary to obstetrical brachial plexus palsy. Methods: Thirty patients (18 boys, 12 girls; mean age 9 years; range 4 to 15 years) with internal rotation contracture and loss of external rotation and abduction of the shoulder secondary to obstetrical brachial plexus palsy underwent transfer of the latissimus dorsi/teres major tendons to the rotator cuff. In addition, musculotendinous lengthening of the subscapularis and pectoralis major (n=15), pectoralis major (n=9), and subscapularis (n=6) were performed. Nine patients had upper plexus involvement (C5-6), 14 had C5-7 involvement, and seven had complete plexus involvement (C5-T1). According to the Waters and Peljovich classification, all the patients had a congruent glenohumeral joint, which was classified as type 1 in one patient, type 2 in 15 patients, and type 3 in 14 patients. Pre- and postoperative range of motion values of the patients were measured and their motor functions were evaluated with the Mallet scoring system. The mean follow-up period was 47.8 months (range 9 to 84 months). Results: Preoperatively, the mean active abduction was 75.8°, and the mean active external rotation was 25.2°. Postoperatively, the mean abduction and external rotation increased to 138.3° (by 62.5°, 82.5%) and 76.4 degrees (by 51.2°, 203.2%), respectively. Improvements in the degrees of abduction and external rotation were significant (p=0.000). According to the Mallet scoring system, the mean preoperative global abduction and global external rotation scores were 2.97 and 2.43, respectively; the mean Mallet scores for the ability to move the hand to the mouth, neck, and back were 2.50, 2.17, and 2.67, respectively. Postoperatively, the mean global abduction score increased to 3.97 (by 33.7%, p=0.000), and the mean global external rotation score increased to 3.77 (by 55.1%, p=0.000). The mean scores for the ability to move the hand to the mouth, neck, and back were 3.30 (increased by 32%, p=0.000), 3.73 (increased by 71.9%, p=0.000), and 2.30 (decreased by 13.9%, p=0.003), respectively. Postoperative changes in the Mallet scores were all significant. Improvements in abduction and external rotation were not significant between patients ≤9 years and >9 years of age (p>0.05). Conclusion: Transfer of the latissimus dorsi and teres major tendons to the rotator cuff combined with musculotendinous lengthening of the subscapularis and/or pectoralis major provides satisfactory increases in shoulder abduction and external rotation, regardless of the age, in patients with no or minimal glenohumeral joint incongruency.OBJECTIVES We evaluated the results of latissimus dorsi and teres major tendon transfer to the rotator cuff together with musculotendinous lengthening of the subscapularis and/or pectoralis major muscles in patients with internal rotation contracture and decreased external rotation and abduction secondary to obstetrical brachial plexus palsy. METHODS Thirty patients (18 boys, 12 girls; mean age 9 years; range 4 to 15 years) with internal rotation contracture and loss of external rotation and abduction of the shoulder secondary to obstetrical brachial plexus palsy underwent transfer of the latissimus dorsi/teres major tendons to the rotator cuff. In addition, musculotendinous lengthening of the subscapularis and pectoralis major (n=15), pectoralis major (n=9), and subscapularis (n=6) were performed. Nine patients had upper plexus involvement (C5-6), 14 had C5-7 involvement, and seven had complete plexus involvement (C5-T1). According to the Waters and Peljovich classification, all the patients had a congruent glenohumeral joint, which was classified as type 1 in one patient, type 2 in 15 patients, and type 3 in 14 patients. Pre- and postoperative range of motion values of the patients were measured and their motor functions were evaluated with the Mallet scoring system. The mean follow-up period was 47.8 months (range 9 to 84 months). RESULTS Preoperatively, the mean active abduction was 75.8°, and the mean active external rotation was 25.2°. Postoperatively, the mean abduction and external rotation increased to 138.3° (by 62.5°, 82.5%) and 76.4 degrees (by 51.2°, 203.2%), respectively. Improvements in the degrees of abduction and external rotation were significant (p=0.000). According to the Mallet scoring system, the mean preoperative global abduction and global external rotation scores were 2.97 and 2.43, respectively; the mean Mallet scores for the ability to move the hand to the mouth, neck, and back were 2.50, 2.17, and 2.67, respectively. Postoperatively, the mean global abduction score increased to 3.97 (by 33.7%, p=0.000), and the mean global external rotation score increased to 3.77 (by 55.1%, p=0.000). The mean scores for the ability to move the hand to the mouth, neck, and back were 3.30 (increased by 32%, p=0.000), 3.73 (increased by 71.9%, p=0.000), and 2.30 (decreased by 13.9%, p=0.003), respectively. Postoperative changes in the Mallet scores were all significant. Improvements in abduction and external rotation were not significant between patients ≤ 9 years and > 9 years of age (p > 0.05). CONCLUSION Transfer of the latissimus dorsi and teres major tendons to the rotator cuff combined with musculotendinous lengthening of the subscapularis and/or pectoralis major provides satisfactory increases in shoulder abduction and external rotation, regardless of the age, in patients with no or minimal glenohumeral joint incongruency.

Comparison of intramedullary nail and plate fixation in distal tibia diaphyseal fractures close to the mortise

BACKGROUND In this study, we aimed to compare the functional and radiological results of intramedullary nailing and plate fixation techniques in the surgical treatment of distal tibia diaphyseal fractures close to the ankle joint. METHODS Between 2005 and 2011, 55 patients (32 males, 23 females; mean age 42 years; range 15 to 72 years) who were treated with intramedullary nailing (21 patients) or plate fixation (34 patients) due to distal tibia diaphyseal fracture were included in the study. The average follow-up period was 27.6 months (range, 12-82 months). The patients were evaluated with regard to nonunion, malunion, infection, and implant irritation. The AOFAS (American Orthopaedic Foot and Ankle Society) scale was used for the clinical evaluation. RESULTS No statistically significant difference was found between the two surgical methods with respect to unification time, AOFAS score, accompanying fibula fracture, material irritation, and malunion. Nine patients had open fractures, and these patients were treated with plate fixation (p=0.100). Nonunion developed in three patients who were treated with plates. Infection occurred in one patient. Anterior knee pain was significantly higher in patients who were treated with intramedullary nails. There was no malunion in any patient. CONCLUSION As the distal fragment is not long enough, plate fixation technique is usually preferred in the treatment of distal tibia diaphyseal fractures. In this study, we observed that if the surgical guidelines are followed carefully, intramedullary nailing is an appropriate technique in this kind of fracture. The malunion rates are not significantly increased, and it also has the advantages of being a minimally invasive surgery with fewer wound problems.

Isolated subtalar fusion for neglected painful intra-articular calcaneal fractures

OBJECTIVE The objective of this study was to evaluate the radiological and clinical outcomes of treatment of subtalar arthrodesis in patients developing talocalcaneal arthrosis secondary to intra-articular calcaneal fractures. METHODS The study included 20 patients (21 feet) who underwent subtalar arthrodesis due to symptomatic subtalar arthrosis following conservative treatment for intra-articular calcaneal fracture between 2005 and 2011. Autograft or allograft was used in 11 patients. Patients were evaluated clinically using the American Orthopedic Foot and Ankle Society (AOFAS) ankle hindfoot score. Hindfoot alignment, quality of subtalar fusion and arthritis occurring in other joints were used for the radiological evaluations. RESULTS Mean duration of follow-up was 43 (range: 21 to 83) months. Mean preoperative AOFAS score was 61.7 (range: 40 to 67) and mean postoperative AOFAS score was 84.2 (range: 65 to 94). The difference between scores was statistically significant (p=0.001). Six patients had excellent, 8 good and 6 fair results. Complete fusion was achieved in 19 patients (20 feet). In 2 patients, arthritic changes were radiologically observed in the midtarsal joints. These changes were not symptomatic. There were no statistically significant differences between pre- and postoperative radiological measurements. No patients experienced malunion. CONCLUSION While subtalar arthrodesis appears to provide radiological and clinical benefits, it may cause moderate and asymptomatic osteoarthritis in the midtarsal joints.

An effective treatment for hip instabilities: pelvic support osteotomy and femoral lengthening

OBJECTIVE In this study, we evaluated the effectiveness of pelvic support osteotomy treatment in hip instabilities due to various etiologies. METHODS We retrospectively evaluated 21 hips of 20 patients that underwent pelvic support osteotomy between 2005 and 2007. Hip instability was caused by a neglected congenital dislocation of the hip in 12 of the patients (13 hips), by septic arthritis in 7 and by an unsuccessful total hip arthroplasty due to infection in the last patient. The mean age of the patients was 22.6 (range: 12 to 34) years. Osteotomy sites were fixed using monolateral external fixators in 11 patients, Ilizarov circular fixators in 8, and locking plates for both hips of the remaining patient. The mean follow-up period was 33.45 (range: 16 to 45) months. RESULTS The mean Harris score increased from 48.3 preoperatively to 80.1 postoperatively. Preoperative mean limb length discrepancy was 53.3 mm and mean proximal migration was 42.9 mm. Residual limb length discrepancy was reduced to 16 mm after an average lengthening of 63.3. The preoperative Trendelenburg gait disappeared completely in 13 of 21 hips and was improved in 8 hips. Sixteen of the 20 patients (17 hips) expressed satisfaction with the operation. CONCLUSION Pelvic support osteotomy is a good treatment option to overcome hip instability as it improves pain and equalizes limb length.

Shortening and secondary relengthening for chronically infected tibial pseudarthroses with poor soft tissues

BackgroundThe treatment of chronically infected tibial pseudarthroses with poor soft tissues ends with amputation on many occasions. Aggressive débridement of bone and soft tissue and reconstruction of the extremity, performed as a limb salvage procedure, is an alternative treatment option to amputation.MethodsOur patients had a mean age of 42 years. According to the Paley classification, one of the patients had A2 pseudoarthrosis, four had B2, and three had B3. One had localized infection, whereas the other seven had diffuse infection, according to the Cierny-Mader system. The mean duration of the infection was 10.75 years, and the mean number of previous operations was 5.13. The mean shortness was 2.4 cm, and the mean bone defect was 1 cm.ResultsThe mean primary shortening was 8.6 cm, the mean duration of the fixator stay was 9.6 months, and the mean distraction index was 39.1 days/cm. The mean duration of follow-up was 25 months. The bone results were excellent in four cases, good in two, and fair in the other two. The functional results were excellent in one patient, good in six, and fair in one. A total of 11 minor and 3 major complications were seen during the treatment, and one case resulted in amputation.CoclusionsDespite the high rate of complications, our treatment method enabled limb salvage for patients who had previously been candidates for amputation. With this treatment, there is less need for a second operation, and an additional operation is not necessary for soft tissue coverage.

Perioperative versus postoperative measurement of Taylor Spatial Frame mounting parameters

OBJECTIVE The aim of this study was to determine the differences, if any, between application parameters for the Taylor Spatial Frame (TSF) system obtained during surgery under fluoroscopy and after surgery from digital radiography. METHODS This retrospective study included 17 extremities of 15 patients (8 male, 7 female; mean age: 21.9 years, range: 10 to 55 years) who underwent TSF after deformity and fracture. Application parameters measured by fluoroscopy at the end of surgery after mounting the fixator were compared with parameters obtained from anteroposterior and lateral digital radiographs taken 1 day after surgery. RESULTS Fixator was applied to the femur in 8 patients, tibia in 6 and radius in 3. Mean time to removal of the frame was 3.5 (range: 3 to 7) months. Mean perioperative anteroposterior, lateral and axial frame offsets of patients were 9.1 (range: 3 to 20) mm, 18.1 (range: 5 to 37) mm and 95.3 (range: 25 to 155) mm, respectively. Mean postoperative anteroposterior, lateral and axial frame offset radiographs were 11.8 (range: 2 to 30) mm, 18 (range: 6 to 47) mm and 109.5 (range: 28 to 195) mm, respectively. There was no statistically significant difference between the groups (p>0.05). CONCLUSION While measurements taken during operation may lengthen the duration in the operation room, fluoroscopy may provide better images and is easier to perform than digital radiography. On the other hand, there is no difference between measurements taken during perioperative fluoroscopy and postoperative digital radiography.

Evaluation of anxiety levels in patients with chronic orthopedic diseases

OBJECTIVE The aim of this study was to evaluate the variables that affect anxiety levels in patients with chronic orthopedic diseases and develop motivational methods to manage these problems. METHODS The study included a total of 100 patients (55 males, 45 females; mean age: 46.8 years; range: 18 to 83 years) that either underwent surgical procedures due to orthopedic diseases lasting for a minimum of one year and not responsive to conservative treatment methods, or were hospitalized due to the complications arising after orthopedic surgical procedures. Psychological evaluation was made using the State-Trait Anxiety Inventory (STAI) forms TX 1 and 2. Data were analyzed using the SPSS 11.0 and evaluated with the ANOVA, Tukey, Students t and post hoc tests. A value of p≤0.05 was considered significant. RESULTS Mean state anxiety and trait anxiety scores were 43.08 and 42.61, respectively. Depression was diagnosed in 24 of patients and anxiety disorder in 29. Changes in the treatment modality were necessary in 4 patients. CONCLUSION Mental and behavioral disorders are rather common in patients with chronic orthopedic diseases. Treatment modalities used for such patients should be established in a bio-psycho-social manner with regards to the psychological and social aspects of the disease.

A novel biological reconstruction of tibial bone defects arising after resection of tumors.

The purpose of this paper is to describe a biologic reconstruction strategy for defects after resection of malignant tibia tumors. Limb-sparing surgery was used for 4 patients with malignant tibia tumors. All patients were male, with an average age of 39.5 years (range: 34-46 years). Mean length of the resected tibia segment was 135 mm (range: 120-150 mm). The defects were primarily reconstructed with bone cement and locked plate until completion of the medical treatment of the tumor. The bone transport was made through locked plate, and the docking site was grafted at the final stage. Mean follow-up period was 49.75 months (range: 71-22 months). Mean distraction index was 1148 mm/days (range: 1130-1175 mm/days), and mean external fixation time was 167 days (range: 152-187 days). According to Paley, functional results were excellent in 2 cases and good in the other 2 cases. Radiological results were excellent in all cases. Two major and 2 minor complications were observed. In this method, stable internal fixation and active usage of extremities are provided until biological reconstruction, and possible wound problems can be completely eliminated during the duration of medical treatment of the tumor.

Salter innominate osteotomy in the treatment of late presentation Perthes disease

Purpose The aim of this study was to evaluate the clinical and radiological results of patients presenting older than eight years and treated with Salter osteotomy for Perthes disease. Method Seventeen patients (18 hips) with late presentation of Perthes disease treated with Salter osteotomy. Sixteen males were identified. The average age of patients was 8.8 years (range 8-12). Preoperation radiographs were analysed for lateral pillar staging, centre-periphery (CP) angle, Sharp acetabular index, acetabular depth index, acetabular covering percentage and Cross-over sign. Final follow-up radiograph were classified using modified Stulberg grade. Results The average follow-up of the patients was 78 months (range 40-104). During the surgery, seven hips were found to be lateral pillar grade B, three hips grade B/C and 8 hips grade C. In the final examination, 10 hips were evaluated as good (Stulberg 1 or 2), seven as medium (Stulberg 3) and one as bad (Stulberg 4). There was shortening in four patients who were all either Stulberg stage 3 or 4. A meaningful difference was detected between the pre-operation and post-operation radiographic values, regardless of the surgical staging. However, no statistical difference was found between the patients in Stulberg stage 3 or 4 and stage 1 or 2 for radiographic variables. Conclusion Salter osteotomy can be used to treat older patients with lateral pillar stage B, B/C and C at presentation.

Closed Total Dislocation of Talus Without Any Accompanying Fractures

Total talar dislocation, ie, disruption of the talus from the calcaneus, navicula, and tibia, is a rare and severe injury. We present a case of closed peritalar dislocation without any accompanying fractures and, thus, discuss the conflicts encountered in this rare injury. A 25-year-old male patient presented with severe pain, swelling, and deformity in his right ankle within 30 minutes of a fall from a height. There were no wounds around the ankle. Radiographs revealed that the talus was disrupted from the calcaneus, navicula, and tibia moving in the anterolateral direction. No accompanying fractures were seen in the talus or in surrounding bones. After an unsuccessful closed reduction attempt, a further decision was open reduction. It was seen that the interposed joint capsula was preventing reduction. After reduction, stability of the ankle was checked and found to be satisfactory, so no fixation material was used. It has been 2 years since the first injury, and the patient is functioning well, with no pain. The ankle has the same range of motion as the unaffected side. No sign of an avascular necrosis or sclerosis is seen on the final radiographs. Closed total dislocation of the talus without any accompanying fractures is a rare entity. The injury is open to various important complications, such as avascular necrosis, infection in patients with open wounds, and arthritic changes. To achieve a good outcome, early reduction of the dislocation has key importance.