Cumhur Kesemenli

Treatment of multifragmentary fractures of the femur by indirect reduction (biological) and plate fixation

We present a retrospective review of the results of 43 multifragmentary femur fractures treated under the principle of indirect reduction (biological) and plate fixation. Fractures were caused by high-energy trauma in all patients. Sixteen were subtrochanteric, 14 diaphyseal and 13 supracondylar. There were 13 open fractures. In six of the patients with diaphyseal fractures, a plate was inserted through isolated proximal and distal incisions only, deep to the vastus lateralis. None of the fractures was treated with bone graft. The mean follow-up time was 28.3 months. Union was achieved in 41 patients within a mean period of 4.25 months. There was delayed union in one patient (subtrochanteric), non-union in two, infection in three, malunion in three, leg shortening in six and mild knee stiffness in seven. In eight patients with diaphyseal fractures in whom a single incision was performed, the average time for fracture healing was 4.14 months in seven and non-union developed in one. In six patients with diaphyseal fractures, in whom proximal and distal incisions were performed, the average time for fracture healing was 4 months. There was no difference (P>0.05) between single and double incision with reference to infection and time to union, but the indirect reduction methods must be meticulously implemented. The implants we used are cheaper and more easily supplied than many others. The success rate is high when the technique is correctly implemented. We believe that this is a treatment of choice in countries with low socioeconomic status, no efficient health insurance system and no intraoperative image intensification.

Treatment of closed femoral diaphyseal fractures with external fixators in children

Abstract From August 1992 to July 1996, 57 patients with closed femoral fractures were treated by external fixator in the Orthopaedic and Traumatology Clinics, School of Medicine, Dicle University. The technique was applied to children with closed femoral fractures. Their mean age was 6 (range 4–12) years old. The mean hospitalisation period was 8 (range 5–15) days. Fixators were removed on an average of 55 (range 38–79) days. The mean follow-up period was 18 (range 9–36) months. Pintract infection was observed in 3 and refracture in 1 patient. Infection was controlled with oral antibiotics and local dressing. An external fixator was applied to a patient in whom refracture developed. No patient had malunion, nonunion, or leg length discrepancy. We propose that external fixation in closed femoral shaft fractures of children could be a rational alternative mode of therapy, since it has some advantages and can be easily removed without undergoing a second round of anaesthesia.

Effect of chemotherapeutic agents on distraction osteogenesis. An experimental investigation in rabbits.

Abstract Limb-salvage operations such as vascularised or non-vascularised osseous grafts and allograft and callus distraction methods have replaced amputations because of the increase in the life expectancy of patients with malignant tumours. In this study we aimed to evaluate the effects of chemotherapeutic agents on distraction osteogenesis. For this purpose, 23 rabbits randomly divided into two groups were included in the study. The experimental group and the control group consisted of 12 rabbits and 11 rabbits, respectively. The experimental group were administered chemotherapeutic agents with the protocol identified in the osteogenic sarcoma regimen. All the subjects were corticotomised in the metaphyseal-diaphyseal region, and both groups underwent distraction with a circular ring fixator. X-ray films, bone scintigraphy and histopathological examination were performed three times during the study. No difference between the two groups was observed in radiological, scintigraphical and histopathological studies carried out before the distraction period and following the end of the distraction period. In this study, it was shown that the use of antineoplastic drugs has no significant negative effect on distraction osteogenesis applied for reconstruction in rabbits. We think that it can be an alternative treatment method in humans as well.

Problem fractures associated with gunshot wounds in children.

Twenty-seven fractures in 22 children (14 female, 8 male; average age: 10.5) who suffered gunshot wounds were retrospectively evaluated. Fourteen of the fractures were caused by high-velocity weapons, four by low-velocity weapons, and nine by shotguns. One of the fractures was undisplaced, two were displaced, 10 were comminuted, seven were comminuted and displaced, and seven had bony defects. Accompanying pathologies included four physeal, three articular, four visceral, four arterial, six peripheral nerve, and one spinal cord injury. Initial treatment involved external fixation in 15 patients and internal fixation in one patient for bone stabilization, while the remaining patients were treated conservatively.Late-stage surgery was necessary to achieve soft-tissue coverage in three patients and to achieve union in six patients. Major complications included amputation in one patient, non-union in two, delayed union in one, osteomyelitis in one, paraplegia in one, and loss of peripheral nerve functions in three. The treatment of fractures associated with firearm injuries in children is never simple. Fracture defects, accompanying peripheral nerve damage and involvement of the joint negatively is affect the outcome, increasing the chance that late-stage surgery will be necessary. Internal bone transport appears to be an efficacious technique in the treatment of bone and soft-tissue defects associated with firearm injuries in children.

Is external fixation in pediatric femoral fractures a risk factor for refracture

The aim of this study was to investigate whether external fixation is a risk factor for refracture by comparing the outcomes of children who received three different forms of treatment of femoral fractures. One hundred ninety-two patients treated for femoral fracture between 1990 and 1999 who underwent final examination were assessed. One hundred were treated with hip spica casting after traction, 57 with closed reduction and external fixation, and 35 with open reduction and external fixation. Morbidity results such as time to union, length of hospital stay, refracture, and wire site infection were statistically evaluated. Patients undergoing open reduction had a greater time to union and length of hospital stay and a higher refracture rate. The difference was statistically significant. Wire site infection occurred in all three groups; there was no statistically significant difference between groups. The authors concluded that external fixation is not a risk factor for refracture in the treatment of pediatric closed femoral diaphyseal fractures, and that it may be used with ease in clinics with shortages of personnel and space.

Floating knee in children.

The outcomes of 18 ipsilateral displaced femoral and tibial fractures in 17 children are assessed and a new classification system is proposed. Average age was 8.75 years, and follow-up averaged 3.2 years. In the modified Bohn and Durbin classification used, eight cases were type I, four were type II, three were type IIIa, one was type IIIb, and two were type IV. In tibial fractures there was angulation in three cases, and in femoral fractures there were dislocation and angulation in four cases, refracture in one case, leg length discrepancy in four cases, and asymptomatic knee ligament injury and meniscal tearing in five cases. According to Yue et als criteria, seven outcomes were excellent, eight were good, two were fair, and two were poor. The cases with poor outcomes were those with open knee injury, and those with fair outcomes were those with angulation. It was concluded that knee ligament injuries do not affect the outcome of floating knee trauma in children, although they do in adults, but that open knee injuries do affect the outcome, and operative treatment of the femoral fracture is the treatment of choice for all ages.

Effect of granulocyte-macrophage colony-stimulating factor on treatment of acute osteomyelitis

Abstract Granulocyte-macrophage colony-stimulating factor (GM-CSF) is a cytokine that affects the various developmental steps of hematopoietic cells and enhances the phagocytic activity of these cells. The effect of GM-CSF on acute osteomyelitis, developed in rats, was investigated. For this purpose, osteomyelitis was firstly developed through the direct inoculation of Staphylococcus aureus into rat tibial metaphysis. Twenty-four rats in which diagnosis of osteomyelitis was histopathologically established were divided into two groups. Antibiotic only was given to the first group, and antibiotic as well as GM-CSF to the second group. Rats were followed up for 3 months with plain radiographs and scintigraphic methods using 67Ga-citrate. Material obtained from the rats that had been killed at the end of the 3rd month were histopathologically investigated. One rat in the first group died. In another rat, chronic osteomyelitis developed and fracture was observed. In 12 rats of the second group, physical examination, plain radiographs, and histopathologic findings were normal. In scintigraphic studies with 67Ga-citrate, when the pre- and posttreatment values of the same groups were evaluated by the Mann-Whitney U-test, the mean values at 48 h after treatment were found to be significant (P < 0.05), indicating a decrease in the 2nd group (experimental group). In conclusion, the antibiotics were effective in the elimination of infection only together with neutrophils. In this manner, infections may be eliminated by strengthening the host’s defense mechanism as well as by administering antibiotics. We believe that an adequate number of long-term studies will shed light on this issue. Besides we consider that this factor will be more important in the study of chronic osteomyelitis.

Anthropometric study of patients treated for clubfoot.

The anthropometric characteristics of patients treated for clubfoot were used to investigate whether the dimensions of the foot were affected by the method of treatment. A total of 68 patients followed up for an average of 9 years were divided into three groups: group 1, conservatively treated; group 2, surgically treated; group 3, conservatively treated on one side and surgically treated on the other. The following average discrepancies in foot length were obtained: group 1, 0.91 cm; group 2, 1.5 cm; group 3, 1.09 cm. Toe lengths were shorter to the same extent as the other dimensions of the foot. These discrepancies were statistically significant. The following average discrepancies in foot width were obtained: group 1, 0.05 cm; group 2, 0.37 cm; group 3, 0.054 cm; these were insignificant. The authors believe that the degree of discrepancy may depend not solely on the method, but on the severity of the deformity as well.

Treatment of calcaneal fractures with closed reduction and the Endobutton-assisted technique: short-term analysis.

BACKGROUND Closed reduction and percutaneous pinning, open reduction and internal fixation, and primary arthrodesis are procedures used in the surgical treatment of calcaneal fractures. This study presents short-term clinical and radiologic results of patients with calcaneal fractures treated by closed indirect reduction with Endobutton-assisted minimally invasive osteosynthesis. METHODS Twenty-one feet of 18 patients (four women and 14 men) with calcaneal fractures were retrospectively analyzed. Böhler and Gissane angles were measured from the preoperative, postoperative, and latest follow-up lateral radiographs of the feet. American Orthopaedic Foot and Ankle Society (AOFAS) scores were used for the 6-month and latest follow-up clinical assessments. RESULTS The mean preoperative Böhler angle of 17.1° was corrected to a mean of 20.4° postoperatively. The mean value of this angle measured at the time of latest follow-up was 21.3°. The mean preoperative and postoperative Gissane angles were 116° and 117.8°, respectively. The mean value of this angle measured at the time of latest follow-up was 117.4°. The mean 6-month postoperative AOFAS score was 59.8 points. The mean AOFAS score at the time of latest follow-up (79.1 points) was significantly higher than the mean score 6 months postoperatively (P < .001). Regarding the latest follow-up AOFAS scores, four were poor, four were moderate, ten were good, and three were excellent. CONCLUSIONS With a low learning curve and satisfactory clinical outcomes, this technique can be used in acute, edematous cases with soft-tissue injuries to avoid calcaneal enlargement, infection, and soft-tissue problems.

Revision of the Gunston polycentric knee arthroplasty with total knee arthroplasty

The Gunston polycentric knee arthroplasty, first designed and performed by Frank Gunston in 1971, is the first prosthesis considering the natural knee biomechanics. Although the polycentric knee arthroplasty showed encouraging results to relieve pain and to preserve the preoperative range of motion and joint instability, the improvements in prosthesis design and arthroplasty technology rapidly made the polycentric knee prosthesis obsolete. Herein, we report a 58-year old male patient who had revision of the Gunston polycentric knee arthroplasty with total knee arthroplasty performed 32 years after the initial operation.