Fuat Akpinar

New interlocking intramedullary radius and ulna nails for treating forearm diaphyseal fractures in adults: A retrospective study

INTRODUCTION The treatment goal for diaphyseal forearm fractures in adults is to restore axial and rotational stability. The treatment of these fractures with intrmaedullary locked nailing remains sparse. We therefore evaluated IM nails for treating forearm diaphyseal fractures in adults. METHODS We retrospectively reviewed adult patients with isolated unilateral or bilateral fractures of the radius, ulna, or both, who were treated with closed or mini open reduction with a new IM nail between May 2008 and January 2012 and who were followed for a least 1 year. Patients with a Galeazzi fracture, a pathological fracture or patients with nonunion after previous surgeries were excluded. All patients were allowed full range of motion without any external support. Primary outcomes were Grace and Eversmann rating, Disabilities of the Arm, Shoulder and Hand (DASH) scores. RESULTS The 43 enrolled patients (mean age, 37 years; 32 men) had 59 forearm fractures: 14 isolated radius fractures, 17 isolated ulna fractures (2 bilateral), and 28 fractures of both the radius and ulna. Mean time to fracture union was 13 weeks (range 10-14 weeks) for ulnar fractures and 12 weeks (range 10-13 weeks) for radial fractures. No patient had nonunion, deep infections, or radioulnar synostosis. Followup ranged from 12 to 44 months. Grace and Eversmann ratings were excellent in 38 patients and good in 5. Mean DASH score was 6.5 points (range 0-13.3). CONCLUSIONS Intramedullary nailing of adult forearm diaphyseal fractures appears to be a good alternative to plate osteosynthesis. The advantages are short operative time, minimal invasive techniques, and sufficient stability in all planes that allows early motion without additional fracture support.

Intratendinous Septic Abscess of the Achilles Tendon after Local Steroid Injection

UNLABELLED In the treatment of pathological processes of the skeletal system, local injection of corticosteroid has become a common form of treatment. Although rare, pyogenic abscess can develop secondary to local corticosteroid injection. In this article, we describe the case of a patient who presented with pain, swelling, and hyperemia following local infiltration of corticosteroid about the Achilles tendon. Magnetic resonance image scanning of the Achilles tendon revealed a smoothly shaped intratendinous mass 3 x 1 cm in diameter, extending to the posterosuperior aspect of the calcaneus. A needle aspiration of the suspected abscess revealed S aureus, and subsequent surgical drainage and debridement revealed chronic inflammation secondary to infection at the site of previous local corticosteroid injection. Antibiotic therapy was used following incision and drainage, and recurrence of infection was not detected throughout the duration of follow-up. LEVEL OF CLINICAL EVIDENCE 4.

Biomechanical comparison of antirotator compression hip screw and cannulated screw fixations in the femoral neck fractures.

OBJECTIVE The aim of this study was to compare the biomechanical properties of minimal invasive sliding antirotator compressive hip screw (MIS-A-CHS), and multiple cannulated screws (CS) on a Pauwels type 3 femoral neck fracture model. METHODS A Pauwels type 3 vertical femoral neck fractures was created on 12 third-generation proximal femur models which were divided into two equal groups. The fracture was fixed with three CS in the first group, and MIS-A-CHS in the second group. The axial and rotational stiffness and maximum compression effect were compared between the groups. RESULTS The axial and rotational stiffness and maximum compression were significantly higher in MIS-A-CHS group (912.5 N, 540 N and 10.2 N/m, respectively) than the CS group (627.5 N, 380 N, and 3.9 N/m, respectively). CONCLUSION MIS-A-CHS appears to be a more secure fixation method in Pauwels type 3 femoral neck fractures than the CS.

A tuber ischium avulsion fracture treated with modified subgluteal approach: a case report.

We report a 16-year-old soccer player with a displaced avulsion fracture of the ischial tuberosity sustained during a soccer match. Open reduction and internal fixation were performed using a longitudinal incision and subgluteal approach. The patient returned to sports 6 months following the operation and returned to his preoperative performance at the 16th month postoperative follow-up. Surgical treatment is often avoided for these types of fractures due to complications associated with the sciatic nerve and exposure difficulty. However, we believe that this incision is a safer alternative to existing methods, providing sufficient exposure and avoiding damage to the neurovascular structures. This article aims to review this alternative incision in the surgical treatment of avulsion fractures of the ischial tuberosity.

Distal phalanx fracture in adults: Seymour-type fracture.

Seymour’s fracture is an extra-articular, transverse, physeal, and juxta-epiphyseal open fracture of the distal phalanx seen in childhood. In this study, we present 10 adult cases of fractures localized to the metaphyseal region, 1–2 mm distal to the insertion of the extensor tendon. Mean age was 38 years. Four patients were treated conservatively with a mallet finger splint. Closed reduction and osteosynthesis with Kirschner wires (K-wires) was performed in three of the patients. Three of the patients had open fractures in whom closed reduction could not be performed. They underwent open reduction and osteosynthesis with K-wires. We recommend that extra-articular distal phalanx fractures mimicking mallet finger in adults are called Seymour-type fracture to establish a common language among clinicians to define this type of fracture. These fractures generally occur by hyperflexion of the distal phalanx and can be treated by conservative or surgical methods. The outcomes of conservative and surgical management of Seymour-type fractures depend on the appropriate reduction as well as efficient physical therapy.

Interlocking intramedullary ulna nails in isolated ulna diaphyseal fractures: a retrospective study.

OBJECTIVE The aim of this study was to evaluate the results of multifunctional intramedullary (IM) ulna nailing following diaphyseal fracture of the ulna. METHODS Adult patients with isolated fractures of the ulna treated with closed or mini-open reduction using the new IM ulna nail between May 2008 and January 2011 and who were followed for a least one year were retrospectively reviewed. Patients with a pathological fracture or nonunion after previous surgeries were excluded. Functional outcome was assessed using the Grace and Eversmann rating system, patient-reported outcomes using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Wrist flexion and extension was evaluated using a goniometer. RESULTS The 18 patients (13 male, 5 female; mean age: 28 years, range: 18 to 64 years) had a total of 20 isolated ulna fractures (two bilateral). Mean time to fracture union was 13 (range: 10 to 14) weeks. No patient had nonunion, deep infection or radioulnar synostosis. Follow-up time ranged from 12 to 36 months. Grace and Eversmann ratings were excellent in 15 patients, good in 2 and poor in one. Mean DASH score was 8.08 (range: 0 to 17.5) points. CONCLUSION The new IM ulna nails may be considered an alternative method for isolated diaphyseal fractures of the ulna. Advantages of this method include its short operative time, insertion by closed and minimal invasive techniques, use of scope only in reduction and locking control, as well as minimal cosmetic defect, small operative scar and early mobilization without additional fixation.

Tips and tricks in the diagnostic workup and the removal of foreign bodies in extremities

OBJECTIVE The aim of this study was to analyze the diagnostic and therapeutic challenges during the removal of foreign bodies in extremities, and to provide relevant tips and tricks. METHODS The medical records of 295 patients (150 men, 145 women; mean 26.82 ± 16.84 years; range: 3 to 79 years) who underwent foreign body removal from their limbs between February 2005 and July 2011, were retrospectively reviewed. Side of the extremity, foreign body type, location, complaints, imaging technique, the season of injury, the effects of foreign body in the body, the time between injury and extraction, indication for extraction, type of anesthesia, the use of fluoroscopy during the surgical procedure, and complications of surgical intervention were analyzed. RESULTS The injury was in the right limb in 157 patients and in the left limb in 138 patients. Foreign bodies were in the elbow in 4 cases, in the forearm in 6, in the wrist in 6, in the hand in 75, in the hip in 1, in the thigh in 7, around the knee joint in 11, in the knee joint in 6, in the lower leg in 10, in the ankle in 8, and in the foot sole in 161. The season of injury was summer in 148 cases, winter in 107, spring in 35, and autumn in 5. The removed foreign bodies were needles in 216 cases, metallic objects in 33, pieces of glasses in 28, pieces of wood in 10, pieces of plastic in 4, and pieces of stone in 4. The time between the injury and foreign body removal was 1 day in 135 cases, 2 to 10 days in 114, 11 to 30 days in 22, and 30 to 365 days in 13. The removal time was longer than 1 year such in 11 cases. CONCLUSION Foreign body injuries may result in serious complications such as infection, migration and joint stiffness. A throughout history and physical and radiological examinations are of tremendous importance to achieve the best outcome in these patients.

A newly designed intramedullary nail with distal interlocking system for tibia fractures in adults - the clinical results.

BACKGROUND The surgical treatment of fractures of the tibia includes reamed and unreamed options. Reamed nails have mechanical advantages but they significantly harm the endosteal circulation. Unreamed nails spare the endosteal circulation, but provide a less stable fixation. In both systems, immediate full weight-bearing is not possible due to instability related to distal interlocking (DI). Further, DI is responsible for the majority of the fluoroscopy requirement and a significant loss of surgical time. In our study, we present the clinical results of a new intramedullary (IM) nail and system, which allows stable fixation with an unreamed technique that permits immediate full weight-bearing, with a minimum fluoroscopy requirement for DI. METHODS Fifty tibia fractures (49 patients) operated using our new IM system between 2008 and 2010 were evaluated retrospectively. They were allowed full weight-bearing the day after surgery. The patients were followed at least 10 months postoperatively. RESULTS Mean fluoroscopy time was 18 seconds (min: 10, max: 30) for DI. Mean union time was 9 weeks (min: 6, max: 12). There was no neurovascular injury, deep infection, malunion, delayed union, or nonunion. CONCLUSION We demonstrated that our newly developed IM nail and new DI system may be an option to solve the stability problems sourced from the DI screw. It also significantly decreases the requirement of fluoroscopy.

Functional Comparison of Immediate and Late Weight Bearing after Ankle Bimalleolar Fracture Surgery

Aim : The aim of the study is to compare immediate weight bearing with below-knee cast or immobilization with plaster splint in 6 weeks in patients after operative treatment for ankle bimalleolar fractures. Methods : Fifty-three patients with ankle bimalleolar fractures were treated operatively in 2005 to 2010 and then were randomly allocated to two groups. Immediately weight bearing in a below-knee cast (26 patients) and immobilization in a plaster splint for the first six postoperative weeks (27 patients). A mean age 37.9 (min 17; max 72). An average follow-up 26.1 months. (min 14; max 55). All fractures were classified with Lauge-Hansen classification. Functional results of both groups were evaluated with AOFAS for the postoperative one year after surgical treatment. Results : According to the AOFAS scoring system, results were excellent and good in 17 patients in group 1. On the other hand, results were excellent and good in 14 patients in group 2. Conclusion : As a result we think that weight bearing protocol should be advantaged for patients with ankle bimalleolar fractures after surgical treatment immediately.

Olecranon anatomy: Use of a novel proximal interlocking screw for intramedullary nailing, a cadaver study

AIM To define the optimum safe angle of use for an eccentrically aligned proximal interlocking screw (PIS) for intramedullary nailing (IMN). METHODS Thirty-six dry cadaver ulnas were split into two equal pieces sagitally. The following points were identified for each ulna: the deepest point of the incisura olecrani (A), the point where perpendicular lines from A and the ideal IMN entry point (D) are intersected (C) and a point at 3.5 mm (2 mm safety distance from articular surface + 1.5 mm radius of PIS) posterior from point A (B). We calculated the angle of screws inserted from point D through to point B in relation to D-C and B-C. In addition, an eccentrically aligned screw was inserted at a standard 20° through the anterior cortex of the ulna in each bone and the articular surface was observed macroscopically for any damage. RESULTS The mean A-C distance was 9.6 mm (mean ± SD, 9.600 ± 0.763 mm), A-B distance was 3.5 mm, C-D distance was 12.500 mm (12.500 ± 1.371 mm) and the mean angle was 25.9° (25.9° ± 2.0°). Lack of articular damage was confirmed macroscopically in all bones after the 20.0° eccentrically aligned screws were inserted. Intramedullary nail fixation systems have well known biological and biomechanical advantages for osteosynthesis. However, as well as these well-known advantages, IMN fixation of the ulna has some limitations. Some important limitations are related to the proximal interlocking of the ulna nail. The location of the PIS itself limits the indications for which intramedullary systems can be selected as an implant for the ulna. The new PIS design, where the PIS is aligned 20°eccentrically to the nail body, allows fixing of fractures even at the level of the olecranon without disturbing the joint. It also allows the eccentrically aligned screw to be inserted in any direction except through the proximal radio-ulnar joint. Taking into consideration our results, we now use a 20° eccentrically aligned PIS for all ulnas. In our results, the angle required to insert the PIS was less than 20° for only one bone. However, 0.7° difference corresponds to placement of the screw only 0.2 mm closer to the articular surface. As we assume 2.0 mm to be a safe distance, a placement of the screw 0.2 mm closer to the articular surface may not produce any clinical symptoms. CONCLUSION The new PIS may give us the opportunity to interlock IMN without articular damage and confirmation by fluoroscopy if the nail is manufactured with a PIS aligned at a 20.0° fixed angle in relation to the IMN.