Faik Altintas

Importance of screw position in intertrochanteric femoral fractures treated by dynamic hip screw.

BACKGROUND Tip-apex distance greater than 25 mm is accepted as a strong predictor of screw cut-out in patients with intertrochanteric femoral fracture treated by dynamic hip screw. The aim of this retrospective study was to evaluate the position of the screw in the femoral head and its effect on cut-out failure especially in patients with inconvenient tip-apex distance. MATERIALS AND METHODS Sixty-five patients (42 males, 23 females; mean age of 57.6 years) operated by dynamic hip screw for intertrochanteric femoral fractures were divided in two groups taking into consideration the tip-apex distance less (group A; 14 patients) or more (group B; 51 patients) than 25 mm. Patients age and gender, follow-up period, fracture type, degree of osteoporosis, reduction quality of the fracture, position of the screw in the femoral head, number of patients with cut-out failure and Harris hip score were compared. RESULTS The average follow-up time was 41.7 months. The mean tip-apex distance was 17.14 mm in group A and 36.67 mm in group B. One (7.1%) patient in group A and three (5.8%) patients in group B had screw cut-out. Except the screw position, no statistical differences were observed between the two groups with regards to study data. The screw was placed in femoral head more inferiorly (p=0.045) on frontal and more posteriorly (p=0.013) on sagital planes in group B, while central placement of the screw was present in group A. The common characteristics of three patients with screw cut-out in group B was the position of the screw which was located in femoral head more superiorly and anteriorly after an acceptable fracture reduction. CONCLUSIONS Peripheral placement of the screw in femoral head increases tip-apex distance. However posterior and inferior locations may help to support posteromedial cortex and calcar femoral in unstable intertrochanteric fractures and reduce the risk of cut-out failure. LEVEL OF EVIDENCE IV, retrospective series.

Avulsion fracture of the posterior cruciate ligament at the tibial insertion in a child: a case report.

The posterior cruciate ligament (PCL) avulsion fracture from its tibial insertion is a very rare condition in children. An isolated avulsion fracture of PCL in a child and its repair by open reduction and internal fixation with a screw is reported.

Fracture of the tibial tray after total knee arthroplasty

We report a case in which fracture of the metal tibial plate was thought to be caused by a combination of neutral anatomic rotation of the femoral component and an undersized tibial plate. This resulted in medial subsidence and baseplate fracture with loosening of the polyethylene and dislocation of the prosthesis.

Risk factors for acute kidney injury after hip fracture surgery in the elderly individuals.

Objective: We aimed to evaluate possible risk factors assocıated wıth acute kidney injury (AKI) after hip fracture surgery in the elderly individuals. Design: Level II diagnostic study, evidence obtained from prospective cohort study from 1 center with level 2, and 3 patients. Patients: A total of 165 patients (>65 years) with femoral neck fracture were enrolled in this prospective study between 2007 and 2010. Two patients were dropped for inadequate laboratory follow-up data. Patients with kidney failure or renal replacement therapy (RRT) history or AKI at admission were excluded. Intervention: Nephrology consultation was obtained from all patients at admission. All patients had undergone bipolar cemented hip arthroplasty that was performed by the same surgical team in all patients within 24 hours of fracture and admission under the same protocol. Main Outcome Measurements: Serum creatinine (SCr), urine output, and complete blood counts were evaluated at baseline and daily basis thereafter. The AKI was defined based on Acute Kidney Injury Network classification. Hospital charges were converted from Turkish Liras to US dollars and rounded. Results: Among 163 patients, AKI occurred in 25 (15.3%) patients, all within the first 48 postoperative hours. Three (1.8%) patients required RRT. Baseline SCr levels were restored within 4.84 ± 1.34 days on average (3-8 days). No patient required RRT after discharge. The mean hospital stay was 3 days (2-6 days) longer and the hospital charge was 2500 US

Venous thromboembolism prophylaxis in major orthopaedic surgery: A multicenter, prospective, observational study

higher for the patients with AKI. After multivariable adjustment, only lower estimated glomerular filtration rate levels (odds ratio 0.945, 95%confidence interval 0.92-0.96) emerged as an independent predictor for AKI. Conclusion: The AKI represents a frequent complication after hip fracture surgery associated with longer hospital stay and higher treatment costs with increased morbidity. Our results show baseline renal function is an independent predictor of AKI.

Arthroscopic Excision of an Ununited Ossicle Due to Osgood-Schlatter Disease

OBJECTIVES We investigated risk factors for venous thromboembolism (VTE), prophylaxis measures employed, and incidence of symptomatic deep venous thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing major orthopaedic surgery (MOS). METHODS An open, multicenter, prospective, observational study was conducted in 21 medical centers, comprising 899 patients. Of these, 316 patients (35.2%) underwent total hip arthroplasty (THA), 328 patients (36.5%) underwent total knee arthroplasty (TKA), and 255 patients (28.4%) underwent surgery for hip fractures (HF). Pharmacologic prophylaxis was employed in all the patients. RESULTS Risk factors for VTE were seen in 73.2% of the patients, the most common being obesity (72%) and prolonged immobilization (36.3%). Low-molecular-weight heparin (91.1%) and fondaparinux (8.9%) were used for prophylaxis, which was short-term in 273 patients (30.4%) and long-term in 626 patients (69.6%). Mechanical prophylaxis was performed with compression stockings in 610 patients (67.9%) and by intermittent pneumatic compression in 67 patients (7.5%). During three-months of follow-up, symptomatic DVT and PE were seen in eight (0.9%) and four patients (0.4%), respectively. Mortality occurred in 10 patients (1.1%). Complications of major and minor bleeding were seen in eight (0.9%) and 40 (4.5%) patients, respectively. CONCLUSION Effective VTE prophylaxis is associated with low risk of clinically apparent DVT and PE in MOS.

Allogeneic blood transfusion decreases with postoperative autotransfusion in hip and knee arthroplasty

Surgical excision of the ossicles has been suggested for unresolved sequelae of Osgood-Schlatter disease in adults resistant to conservative measures. A 24-year-old, male semiprofessional soccer player had anterior knee pain during sports activity and climbing stairs that had been treated conservatively for 2 years. On physical examination, there was a permanent tibial tubercle with pain. On radiographic examination, an ununited ossicle was seen beneath the patellar tendon. Arthroscopy was performed through the standard low anterolateral and anteromedial portals close to the patellar tendon. Soft tissue at the retropatellar surface and the inflamed infrapatellar fat pad beneath the patellar tendon were debrided with a motorized shaver. Localization of the ununited ossicle was performed by use of an image intensifier. The ossicle was separated from the surrounding soft tissue with a motorized shaver and removed by use of a grasper. After excision of the ossicle, the inflamed surface of the retropatellar tendon was also debrided. The contouring of the irregular surface of the tibial tubercle was performed by use of a motorized bur. After 6 weeks, the patient returned to sports activities without any restrictions. This study showed that all of the described procedures might be done arthroscopically and sports activity may be allowed earlier.

Locked anatomic plate fixation in displaced clavicular fractures

OBJECTIVES We aimed to evaluate the effectiveness of postoperative autotransfusion method on prevention of the need of allogeneic blood transfusion in hip and knee arthroplasty. METHODS Seventy-four patients who underwent 77 hip and knee arthroplasty operations were randomized into control and study groups, and evaluated prospectively. In the knee group (39 patients; 30 females, 9 males; mean age 66.6 years), cemented, cruciate retaining, and bicompartmental arthroplasty was performed under tourniquet control; whereas in the hip group (35 patients; 24 females, 11 males; mean age 59.3 years) cementless arthroplasty with posterolateral approach was performed. None of the patients received preoperative and intraoperative allogeneic blood transfusion. The collected blood in the surgical area was transfused with autotransfusion system to the patients in the study groups at the end of the fourth hour postoperatively. The mean amounts of autotransfused blood in hip and knee groups were 413 mL and 480 mL, respectively. Allogeneic blood transfusion was applied to the patients with hemoglobin level below 8 g/dL, hematocrit level below 25%, and clinical symptoms of anemia. RESULTS Preoperative and postoperative hemoglobin-hematocrit levels did not differ significantly between study and control groups. Allogeneic blood transfusion was applied to one patient (5%) in study and 8 patients (38%) in control groups during knee arthroplasty (p=0.01); whereas 9 patients (53%) in study and 15 patients (79%) in control groups received allogeneic blood transfusion during hip arthroplasty (p=0.044). The amount of allogeneic blood transfusion in study groups was significantly lower than that in control groups (p=0.008 for knee arthroplasty, p=0.048 for hip arthroplasty). CONCLUSION The need and amount of allogeneic transfusion were reduced with postoperative autotransfusion in both knee and hip arthroplasty groups with greater extent in knee arthroplasty.

Surgical treatment for calcaneal intraosseous lipomas

OBJECTIVE We aimed to evaluate the results and complications of open reduction and internal fixation by locked anatomic plates in adult midshaft clavicular fractures. METHODS Sixteen patients (11 males, 5 females; mean age: 39.6 years) who underwent open reduction and internal fixation with locked anatomic plate for displaced-comminuted midshaft clavicular fractures and were followed-up for at least one year were reviewed retrospectively. Complications in the early and late postoperative periods and functional scores according to the Constant and DASH scoring systems from the latest follow-up were evaluated. RESULTS Mean follow-up period was 24.6 (range: 12 to 52) months and mean union time was 13.3 (range: 10 to 23) weeks. None of the patients had superficial and/or deep infections in the early postoperative period or neurovascular complications. Two (12.5%) patients had implant irritation. In two (12.5%) patients, implant failure was detected in the late postoperative period. Delayed union was suspected in these patients and they were operated with longer plate and grafting in the 4th month. At the final follow-up, none of the patients had nonunion or malunion and the mean Constant and DASH scores were 85.5 and 12.8, respectively. Constant scores in patients with complications (p=0.007) and DASH scores in patients with no complications (p=0.001) were significantly lower. CONCLUSION Fixation with locked anatomic plates in displaced midshaft clavicular fractures has lower complication rates. Possible postoperative complications are generally associated with implant irritation and failure. These problems can be avoided with the development in implant technology and new implant designs.

Etiology of coxarthrosis in patients with total hip replacement

Intraosseous lipoma is among rare benign tumors of the bone. The aim of the present study was to evaluate the long-term surgical results of calcaneal lipomas, representing a relatively rare localization for this type of tumors. The present study included 21 calcaneal lipoma cases (22 feet) referred to our podiatry clinic between 1991 and 2001 with complaints of foot and heel pain resistant to conservative treatment for the last 3-6 months. In all cases, the diagnosis of calcaneal intraosseous lipoma was first confirmed radiologically, then histologically. The mean age was 39 years (range 16-62), 15 were females (71%) and 6 were males (29%). One patient had bilateral disease, whereas 11 and 9 patients had right and left calcaneal involvement, respectively. None of the patients have a palpable mass in their foot. For pre-operative differential diagnosis, 3 patients had computerized tomography examination (CT scan) and 8 patients underwent magnetic resonance imaging (MRI). All lesions were totally curetted out with angled curettes. The defect was filled with cancellous autografts taken from the ipsilateral iliac crest. In only four patients, the amount of autograft was not sufficient, so a combination of cancellous allograft and autograft was used. No drain was used. An elastic bandage was wrapped around the foot and ankle, and cold packs were applied to the surgical site. The mean duration of follow up was 94 (45-143) months. Pain improved in 17 feet at 4 months, in an additional 4 feet at 8 months and in the remaining one foot at 12 months. The mean time to the graft consolidation was 5 months (range 3-7 months). There were no recurrences or pathological fractures during the follow up. No wound infection or necrosis was seen at the surgical sites. There were no neurovascular complications. Five cases experienced pain in the iliac bone for 1 month, due to grafting procedures. Although calcaneal intraosseous lipoma accounts for a small portion of cases in the huge differential diagnosis chart for foot pain, it should be kept in mind as a possible diagnosis in unresolved cases. Most of the patients would benefit from non-surgical treatments. But if this is not the case, surgical treatment is indicated. In conclusion, curettage and autogenous bone grafting is an easy and effective method for the surgical treatment of calcaneal intraosseous lipomas.