Erden Erturer

Radiographic and functional results of osteosynthesis using the proximal femoral nail antirotation (PFNA) in the treatment of unstable intertrochanteric femoral fractures.

OBJECTIVES We evaluated the radiographic and functional results of the proximal femoral nail antirotation (PFNA) system in patients with unstable intertrochanteric femoral fractures. METHODS The study included 45 patients (25 women, 20 men; mean age 72 years; range 27 to 97 years) who underwent osteosynthesis using the PFNA for unstable intertrochanteric femoral fractures. The fractures were in the right hip in 25 patients, and in the left hip in 20 patients. The fractures were classified according to the AO system. One patient had an open fracture due to firearm injury (Gustilo-Anderson 3A). The patients underwent surgery within a mean of eight days (range 2 to 21 days) from injury. The mean hospital stay was 13.5 days (range 4 to 25 days). Closed reduction was achieved in all the patients. The results were assessed clinically and radiographically. The neck-shaft angle of the femur (collodiaphysial angle) and the tip-apex distance were measured. The position of the helical screw within the femoral head was determined using the method of Cleveland and Bosworth. Clinical evaluation was made using the Harris hip score. Perioperative and postoperative complications were recorded. The mean follow-up period was 17.3 months (range 6 to 23 months). RESULTS The mean operation time was 37.8 min (range 22 to 118 min) and the mean blood loss was 225 ml (range 150 to 450 ml). During surgery, femoral shaft fracture occurred in three patients, and greater trochanter fracture occurred in nine patients. Union was obtained in all the patients. Reduction was poor in four patients (8.9%), acceptable in seven patients (15.6%), and good in 34 patients (75.6%). The mean collodiaphysial angle was 136.7 degrees (range 125 degrees to 148 degrees). The tip-apex distance was <25 mm in 36 patients (80%), and =or>25 mm in nine patients (20%). The position of the helical screw in the femoral head was appropriate in 38 patients (84.4%). Postoperative complications included secondary varus (n=2, 4.4%), calcification at the tip of the greater trochanter (n=7, 15.5%), sensitivity over the fascia lata (n=7), medial thigh pain (n=11, 24.4%), and screw cut-out (n=1, 2.2%). Nine patients developed femoral shortness (mean 9.4 mm; range 8 to 13 mm). Screws showed lateral displacement in five patients (11.1%), which was less than 5 mm in four patients. Secondary surgery was required in four patients (8.9%). The mean Harris hip score was 77.8. Harris hip scores were very good in 11 patients (24.4%), good in 19 patients (42.2%), moderate in nine patients (20%), and poor in six patients (13.3%). CONCLUSION Due to advantages of high union rate, early postoperative mobilization, and short operation time, PFNA osteosynthesis is the method of choice for surgical treatment of unstable intertrochanteric femoral fractures..

Long-term radiographic complications following treatment of unstable intertrochanteric femoral fractures with the proximal femoral nail and effects on functional results

OBJECTIVES We aimed to evaluate radiographic complications occurring after treatment of unstable intertrochanteric hip fractures with the Proximal Femoral Nail (PFN) and their effect on functional results. METHODS The study included 35 patients (23 women, 12 men; mean age 71 years; range 62 to 111 years) who were treated with the PFN for unstable intertrochanteric hip fractures. According to the AO classification, there were 12 type AII-1, 12 AII-2, 3 AII-3, 3 AIII-1, 5 AIII-3 fractures. The mean time to surgery was 13 days (range 5 to 32 days). Closed reduction was achieved in 31 patients. The patients were evaluated clinically (Harris hip score) and radiographically after a mean follow-up of 32.4 months (range 26 to 52 months) and complications were recorded. RESULTS Reduction was assessed as good or acceptable in all the patients. The mean tip-apex distance was measured as 24.2 mm (range 16 to 40 mm). Complete union was achieved in all but two patients. The mean Harris hip score was 82.1. The results were excellent in 11 patients (31.4%), good in 15 patients (42.9%), fair in seven patients (20%), and poor in two patients (5.7%). Radiographic complications mainly included secondary varus displacement in nine patients (25.7%), and calcification at the tip of the greater trochanter in two patients (5.7%). Secondary varus displacement was due to cut-out of the proximal screws (n=2), screw loosening due to collapse of the fracture site (n=2), and reverse Z-effect (n=5). Clinical results were good in two patients with calcification at the tip of the greater trochanter. Of nine patients with secondary varus displacement, the results were excellent or good in six patients, fair in two patients, and poor in one patient. Five patients (14.3%) required a subsequent operation. CONCLUSION The correct position of the osteosynthesis material and use of an intramedullary nail providing a stronger fixation of the proximal part may reduce mechanical complications following the treatment of unstable intertrochanteric hip fractures.

Analysis of risk factors affecting mortality in elderly patients (aged over 65 years) operated on for hip fractures

OBJECTIVES We analyzed the relationship between mortality rates and preoperative medical conditions and vital factors in elderly patients (aged over 65 years) operated on for hip fractures. METHODS The study included 92 patients (56 females, 36 males) who were operated on for hip fractures and had follow-up data up to 36 months. The mean age was 76 years (range 65 to 96 years) for women, and 74 years (range 65 to 92 years) for men. The fractures were intertrochanteric in 54 patients (58.7%), and in the femur neck in 38 patients (41.3%). The patients were divided into three risk groups, namely, low (n=23, 25%), moderate (n=45, 48.9%), and high (n=24, 26.1%), according to our institutional Sişli Etfal risk factor assessment scale. Relationships were analyzed between mortality and sex, preinjury ambulation level, cognitive functions, and time to surgery in each risk group. RESULTS One-year mortality rates were 6.9%, 31.4%, and 80% in low-, moderate-, and high-risk groups, respectively. The risk scores were significantly correlated with mortality rates (r=0.664; p<0.05). Thirty-four female patients (60.7%) and 18 male patients (50%) were dead at the end of 36 months. No significant relationship was found between mortality rates and sex, cognitive functions, and time to surgery (p>0.05). Mortality within the first three postoperative months among patients who could only ambulate with a walker preoperatively was significantly higher than those who could walk independently or with an aid (p=0.037). CONCLUSION A risk assessment system covering all risk factors to estimate postoperative mortality following surgery for hip fractures would be helpful in planning treatment.

The results of open reduction and screw or K-wire fixation for isolated type II radial head fractures

OBJECTIVES We evaluated the functional and radiographic results of patients treated with open reduction and screw or K-wire fixation for isolated Mason type II radial head fractures. METHODS The study included 21 patients (14 men, 7 women; mean age 36 years; range 25 to 58 years) who were treated with open reduction followed by mini screw (n=11) or K-wire (n=10) fixation for isolated type II radial head fractures. Functional results were evaluated using the modified Morrey functional rating index. Radiographically, osteoarthritis or heterotopic ossification were investigated. The mean follow-up was 30.5 months for K-wire fixation, and 32.1 months for screw fixation. RESULTS Union was achieved in all the patients, within a mean of 6.2 weeks with screw fixation, and 5.8 weeks with K-wire fixation. The range of motion of elbow flexion-extension and pronation-supination were 131.4 degrees and 144.4 degrees with screw fixation, and 127.5 degrees and 146.5 degrees with K-wire fixation, respectively. The mean Morrey index was 94.5 (range 73 to 100) with screw fixation, yielding excellent or good results in 10 patients. One patient whose result was fair had a 2-mm step-off on the joint surface, resulting in osteoarthritis. The mean Morrey index was 92.1 (range 73 to 100) in the K-wire group, with excellent or good results in nine patients, and fair in one patient. All the patients returned to preinjury work in a mean of 11.7 weeks and 12.5 weeks in screw and K-wire groups, respectively. Heterotopic ossification was not observed. The two fixation groups were similar with respect to union time, joint range of motion, Morrey score, and time to return to work (p>0.05). CONCLUSION Our results suggest that both methods provide sufficient fixation resulting in similar functional results in isolated type II radial head fractures.

Late results of replantations in tip amputations of the thumb

OBJECTIVES We retrospectively evaluated replantations performed for Tamai type 1 thumb amputations. METHODS The study included 14 patients (12 males, 2 females; mean age 28 years; range 14 to 40 years) whose replanted thumbs survived following replantation for Tamai type 1 amputations in the distal nail fold of the thumb. Central digital artery anastomosis was performed in all the cases. Four patients with an appropriate vein had a single volar vein anastomosis. Nerve repair could be possible in only three patients. Sensory evaluations were made with the Semmes-Weinstein monofilament test, static and moving two-point discrimination tests, and vibration test. In addition, patients were evaluated with respect to atrophy in the replanted part, nail-bed deformities, and cold intolerance. The mean follow-up period was 11 months (range 6 to 48 months). RESULTS The Semmes-Weinstein test was green (range 2.83 to 3.22) in five patients (35.7%), blue (range 3.22 to 3.61) in eight patients (57.1%), and purple (range 3.84 to 4.31) in one patient (7.1%). The mean static and moving two-point discrimination test results were 6.9 mm (range 3 to 10 mm) and 4.5 mm (range 3 to 6 mm), respectively. Compared to the intact fingers, vibration was increased in six thumbs (42.9%), decreased in six thumbs, and the same in two thumbs (14.3%). Atrophy of the replanted parts was observed in five patients (35.7%). Three patients (21.4%) complained about cold intolerance, and three patients had nail-bed deformities. The mean time to return to work was 3.2 months (range 2 to 6 months). CONCLUSION Despite technical difficulties, thumb replantations yield good functional and aesthetic results. Sensory recovery is sufficient even after tip replantations without nerve repair.

Ligament reconstruction using the Fulkerson-Watson method to treat chronic isolated distal radioulnar joint instability: short-term results

OBJECTIVE Isolated distal radioulnar instability may remain unrecognized during the acute period of trauma as it is difficult to diagnose, and does not become obvious until later when it has become chronic. We present early results in patients who underwent stabilization with extraarticular ligament reconstruction (Fulkerson-Watson reconstruction). METHODS Four women and 1 man underwent surgery for chronic isolated distal radioulnar joint instability demonstrated in X-rays and magnetic resonance images. Arthroscopy revealed avulsion of the triangular fibrocartilage complex from the point of insertion in 3 patients, and peripheral tears in 2 patients. The peripheral tears were debrided arthroscopically. All patients had an adequate sigmoid notch and therefore underwent ligament reconstruction using the Fulkerson-Watson method. Postoperative evaluations were done with MRI. RESULTS Mean follow-up was 15.5 months (range 6-26 months). Stability was achieved in all patients. The mean Quick-DASH symptom score decreased from 18.63 (15.90-22.72) to 6.81 (2.27-9.09) after surgery. A mean visual analogue score to assess pain decreased from 7.32 (6.30-8.40) to 1.88 (1.50-2.30) after surgery. Preoperative and postoperative measurements were 26° (passive 44°) and 47° (passive 65°) for active supination, 18° (passive 45°) and 49°(passive 68°) for active pronation, 20° (passive 43°) and 42° (passive 60°) for active wrist flexion,and 38° (passive 52°) and 45° (passive 59°) for active wrist extension. CONCLUSION Surgical revision of distal radioulnar joint instability using Fulkerson-Watson reconstruction is easier than intraarticular techniques and satisfactorily re-establishes stability, provided that the sigmoid notch is adequate.

Klippel–Feil syndrome with osteopoikilosis in a young lady and her four female relatives with osteopoikilosis

Osteopoikilosis is a rare, usually asymptomatic, autosomal dominant bone disorder, which is usually found incidentally on X-ray. Klippel–Feil syndrome is a rare disorder characterized by the congenital fusion of any two of the seven cervical (neck) vertebrae. It is caused by a failure in the normal segmentation or division of the cervical vertebrae during the early weeks of fetal development. In this case report, we describe a woman with osteopoikilosis associated with type 2 Klippel–Feil syndrome. Additionally, four female members of her family had osteopoikilosis. We state that possible syndromes that can go with osteopoikilosis must be kept in mind in case of an incidental diagnosis in daily practice.

Bilateral L5 Radiculopathy Due to Osteoporotic L1 Vertebral Fracture: A Case Report

Abstract Background: The true incidence of osteoporotic vertebral fractures is not well defined because many osteoporotic vertebral fractures are asymptomatic. Although the true incidence of neurological compromise as a result of osteoporotic vertebral fractures is not known, it is thought to be low. In this case report, we present a case of L1 osteoporotic vertebral fracture causing bilateral L5 nerve root compression and manifestation of bilateral foot-drop. Methods: Pedicle screws were inserted in the vertebrae, 2 above and 2 below the LI vertebra. A temporary rod was placed on the left. An LI right hemilaminectomy via a posterior approach and a corpectomy were performed. The spinal cord was decompressed. Anterior fusion was carried out by placing titanium mesh cage into the vertebrectomy site as a strut graft via posterior approach, and posterolateral fusion with spongious allografts were added to the procedure. Results: Two years later the patient was completely symptom free and receiving medical treatment for osteoporosis, which was diagnosed as primary type. Conclusion: If a fracture is detected on the posterior wall of the vertebral body in computerized tomography (CT) examination with plain radiographs, a magnetic resonance imaging (MRI) examination should be conducted in the presence of symptoms and physical findings suggestive of neurological compression. Follow-up neurological examinations should be carried out, and it should be kept in mind that most of the neurological symptoms may develop late and manifest as radiculopathy. The majority of the osteoporotic vertebral fractures can be managed conservatively with bed rest and orthosis, but cases with accompanying neurological deficit should be managed surgically using decompression and stabilization by fusion and instrumentation.

Early mobilization with customized TLSO brace in thoracolumbar burst fractures

Objective: This study aimed to research the effectiveness of customized thoracolumbosacral orthosis treatment for stable burst type thoracolumbar vertebral fractures without neurological deficits. Methods: The study included 26 patients (14 males, 12 females; mean age: 46.03 years; range: 18 to 64 years) conservatively treated for thoracolumbar (T11-L2) burst type vertebral fractures according to Denis classification between 2002 and 2009. Etiology were a fall from various heights in 12 patients (46.2%), motor vehicle accidents as an occupant in 7 (26.9%) and as a pedestrian in 4 (15.4%), and simple fall in 3 (11.5%). None of the patients had neurologic deficit and no damage was found in the posterior ligamentous complex in MRI evaluations. Denis pain and functional scales were used in the clinical evaluation. Local kyphosis angle, sagittal index and height loss percentage were measured in the radiologic evaluation. Post-fracture and follow-up values were compared. Mean follow-up period was 41.30 (range: 14 to 80) months. Results: Mean pain and functional scores were 1.65 and 1.15 points, respectively, at the final follow-up. Twenty patients returned to their pre-trauma work and activities completely and six patients with small limitations. Mean period for returning to work was 3.64 (range: 2 to 6) months. Local kyphosis angle, sagittal index and height loss percentage values increased significantly at follow-up (p<0.05). Conclusion: The conservative treatment of stable thoracolumbar burst fractures is widely accepted. Early mobilization with customized TLSO brace appears to produce effective functional results despite loss of vertebral body height.

Strategies for Proximal Femoral Nailing of Unstable Intertrochanteric Fractures: Lateral Decubitus Position or Traction Table.

Background: The aim of this prospective randomized study was to compare the traction table and lateral decubitus position techniques in the management of unstable intertrochanteric fractures. Methods: Eighty-two patients with unstable intertrochanteric fractures between 2011 and 2013 were included in this study. All patients were treated surgically with the Proximal Femoral Nail Antirotation implant (DePuy Synthes). Patients were randomized to undergo the procedure in the lateral decubitus position (42 patients) or with the use of a traction table (40 patients). Patients whose procedure was not performed entirely with a semi-invasive method or who required the use of additional fixation materials, such as cables, were excluded from the study. The groups were compared on the basis of the setup time, surgical time, fluoroscopic exposure time, tip-to-apex distance, collodiaphyseal angle, and modified Baumgaertner criteria for radiologic reduction. Results: The setup time, surgical time, and fluoroscopic exposure time were lower and the differences were statistically significant in the lateral decubitus group compared with the traction table group. The collodiaphyseal angles were significantly different between the groups in favor of the lateral decubitus method. The tip-to-apex distance and the classification of reduction according to the modified Baumgaertner criteria did not demonstrate a statistically significant difference between the groups. Conclusions: The lateral decubitus position is used for most open procedures of the hip. We found that this position facilitates exposure for the surgical treatment of unstable intertrochanteric fractures and has advantages over the traction table in terms of set up time, surgical time and fluoroscopic exposure time.