Hakan Başar

Short segment pedicle screw instrumentation with an index level screw and cantilevered hyperlordotic reduction in the treatment of type-A fractures of the thoracolumbar spine

The purpose of this study was to evaluate and compare the effect of short segment pedicle screw instrumentation and an intermediate screw (SSPI+IS) on the radiological outcome of type A thoracolumbar fractures, as judged by the load-sharing classification, percentage canal area reduction and remodelling. We retrospectively evaluated 39 patients who had undergone hyperlordotic SSPI+IS for an AO-Magerl Type-A thoracolumbar fracture. Their mean age was 35.1 (16 to 60) and the mean follow-up was 22.9 months (12 to 36). There were 26 men and 13 women in the study group. In total, 18 patients had a load-sharing classification score of seven and 21 a score of six. All radiographs and CT scans were evaluated for sagittal index, anterior body height compression (%ABC), spinal canal area and encroachment. There were no significant differences between the low and high score groups with respect to age, duration of follow-up, pre-operative sagittal index or pre-operative anterior body height compression (p = 0.217, 0.104, 0.104, and 0.109 respectively). The mean pre-operative sagittal index was 19.6° (12° to 28°) which was corrected to -1.8° (-5° to 3°) post-operatively and 2.4° (0° to 8°) at final follow-up (p = 0.835 for sagittal deformity). No patient needed revision for loss of correction or failure of instrumentation. Hyperlordotic reduction and short segment pedicle screw instrumentation and an intermediate screw is a safe and effective method of treating burst fractures of the thoracolumbar spine. It gives excellent radiological results with a very low rate of failure regardless of whether the fractures have a high or low load-sharing classification score.

Isolated volar surgical approach for the treatment of perilunate and lunate dislocations

Background: Volar and/or dorsal surgical approaches are used for surgical treatment of perilunate and lunate dislocations. There are no accepted approaches for treatment in the literature. We evaluated the functional results of isolated volar surgical approach for the treatment of perilunate and lunate dislocation injuries. Materials and Methods: 9 patients (6 male and 3 female patients average age 34.5 ± 3.6 years) diagnosed with perilunate or lunate dislocations between January 2000 and January 2009 were involved in the study. The reduction was performed through isolated volar surgical approach and K-wire fixation, fracture stabilization with volar ligament repair was performed. Range of wrist joint motion, fracture healing, carpal stability, grip strength, return to work were evaluated and also direct radiographs were taken routinely at each control. The scapholunate interval and the scapholunate angle were evaluated radiographically. Evaluations of the clinical results were done using the DASH, VAS and Modified Mayo Wrist Scores. Results: The physical rehabilitation was started at 6th week, after the K-wires were removed. The average followup was 18.2 months (range 12-28 months). At the final followup, the average flexion extension arc was 105.0 ± 9.6° (74.6% of the other side), the average rotation arc was 138.8 ± 7.8° (81.5% of the other side) and the average radioulnar arc was 56.1 ± 9.9° (86.4% of the other side). The grip strength was 0.55 bar; 83.2% that the uninjured arm. According to the Mayo Modified Wrist score, the functional result was excellent in five patients and good in four and the average DASH score was 22.8. The scapholunate interval was 2.1 mm and scapholunate angle was 51°. Conclusion: The clinical and radiological results of the isolated volar surgical approach were satisfactory. The dorsal approach was not needed for reduction of dislocations during operations. Our results showed that an isolated volar approach was adequate.

The use of intralaminar screws in patients with spinal deformity.

Study Design: Retrospective study. Objective: To demonstrate that intralaminar screws (ILS) can be used as supplements in spinal deformity surgery in the thoracic and lumbar levels in pediatric and adult patients. Summary of Background Data: Rigid posterior fixation of the spine is generally accomplished using pedicle screws, hooks, or wires. ILSs are useful tools when other spinal fixation techniques have failed or the bony anatomy precludes hook or screw placement. Materials and Methods: All spinal deformity patients (primary/revision) operated between 2007 and 2011 were retrospectively reviewed. The patients with ILS were included in the study. The anteroposterior and lateral standing x-rays were evaluated in terms of preoperative and postoperative coronal and sagittal deformities. The number and level of ILS, intraoperative complications, and postoperative complications were noted. Results: There were 20 patients (12 male and 8 female). The mean age was 21.75 years. The mean follow-up period was 17.4 months. Fifty-seven ILS were inserted. Seventeen screws were used in the uppermost to lowermost levels. Forty screws were used in the middle. There was 1 lamina fracture and screw pull out (1.75%). There were 3 canal violations (corrected intraoperative) and 2 instrument prominences which required implant removal. The mean preoperative/postoperative cobb angles were 78.5 degrees/27.8 degrees and the mean preoperative/postoperative kyphosis angles were 57.2 degrees/32.5 degrees, respectively. The loss of correction was 1.2 degrees. There were no neurological deficits and no instrument failures. Conclusions: ILS are safe and effective when used in deformity correction. However, biomechanical studies and randomized controlled trials are needed to conclude whether ILS will be considered a first-line technique, or will remain a technique for salvage situations.

Mid-term radiological and functional results of biological reconstructions of extremity-located bone sarcomas in children and young adults.

Biological reconstruction is a useful option for reconstruction following bone sarcoma resection in children. The mid-term functional and radiological outcomes of biological reconstructions after resection of bone sarcomas in children are presented in this study. Eighteen patients [average age 12.5 years (range 4–22 years)] with primary sarcomas of long bones underwent wide surgical resection and biological reconstruction. The bone defects were managed by intercalary (n=14), osteoarticular (n=3) reconstructions and arthrodesis (n=1) with a vascularized fibular graft (VFG). VFG was combined with a massive allograft in seven lower extremity reconstructions. The average follow-up was 45.7 months (range 25–78 months). Graft union and graft hypertrophy was observed in 17 (94.4%) of 18 patients at 12 months. The VFG–allograft osteointegration rate was 100% at 24 months. The average final follow-up Musculoskeletal Tumor Society (MSTS) scores for lower and upper extremity reconstructions were 79.7% (range 66.6–90%) and 80.9% (range 53.3–100%), respectively. Four (22.2%) complications, including nonunion (n=1), implant failure (n=1), infection (n=1) and skin necrosis (n=1), required reoperation. The disease relapsed in three (16.6%) patients. Defect size and VFG length did not correlate with MSTS scores and radiological parameters (P>0.05). Biological reconstruction with VFG can provide permanent stability and progressively increasing functional and radiological results.

Solitary cystic tuberculosis of the distal femur and proximal tibia in children.

Pediatric skeletal (extraspinal) tuberculosis may mimic pyogenic infections and bone tumors. The aim of this study was to show a multimodality approach to the correct diagnosis and to evaluate the long-term clinical and radiological results of curettage and antituberculosis treatment. Between 2004 and 2012, we treated eight children (five boys, three girls) with histologically proven solitary cystic tuberculosis of the proximal tibia and distal femur. The average age at presentation was 4 years (range, 2–6 years). Except for one case with metadiaphyseal involvement, all lesions were located in the metaphysis and crossed the physis in three. The patients were managed by curettage without bone grafting, followed by antituberculosis therapy. The average follow-up was 4 years (range, 2–7 years). All children achieved complete clinical and radiological healing without any residual lesion or recurrence. In three cases with epiphyseal involvement, the growth plate maintained its function and gradually remodeled within 24 months, without any deformity. No surgical complication was observed. The diagnosis of pediatric skeletal tuberculosis can be made with a good correlation of clinical, radiological, and histological findings. High healing rates can be achieved with surgical debridement and chemotherapy.

Isolated dorsal approach for the treatment of neglected volar metacarpophalangeal joint dislocations

Here, we present the clinical and radiological results of three neglected volar metacarpophalangeal dislocations in 2 patients, which were treated with open reductions 10 and 24 mo after the dislocations. There was a mean of a 20° (range 10°-30°) limitation of extension and a 53.3° (range 30°-70°) limitation of flexion preoperatively. Postoperatively, there was no limitation of extension (at 8 and 12 mo) in any of the fingers. In terms of flexion, one finger had full function, one had a 10° and the last one had a 30° limitation of flexion. Two of the fingers presented anesthesia preoperatively, which improved to hypesthesia postoperatively. One finger had hypesthesia, which improved postoperatively. During surgery, a ruptured dorsal capsule was found to have interposed into the joint, making closed reduction impossible. Our experience with these two patients demonstrated that, even in neglected cases, open reduction using an isolated dorsal approach may result in satisfactory clinical and radiological outcomes.

Functional results of osteosynthesis with mini-plate and screws in metacarpal fractures

Abstract Objectives To evaluate the radiological and functional results of osteosynthesis with mini-plate and screws in metacarpal fractures. Methods In our study 43 patients who were operated between 2009 and 2012 were included. The patients were followed-up for (19.76±5.61) months. The mean age of patients was (31.11±7.81) years (7 females, 36 males). The fracture types were oblique for 19 patients, spiral for 15 patients and transverse for 9 patients. The patients were operated after a mean of 3.4 d (range 3 h-6 d) after the fracture had occurred. Patients were immobilized for 2 weeks with a splint after surgery. Passive joint movements were started on the third days, and active joint movements were started in the second week. Rehabilitation of all patients was done in the same center with supervision of the same physiotherapist. The patients were assessed by total joint range of movement of the finger, grasping strength and Quick-DASH scores. Results No significant differences were detected between fingers of the operated hand with same finger of the healthy hand according to total joint range of movement. Total joint range of movement values were measured perfect for 38 patients, good for 4 patients and medium for 1 patient. There were no significant differences with the corresponding finger on the opposite healthy side according to grasping strength. Soiling in the wound dressing was observed in 1 patient but there was no active drainage. Soiling of the wound dressing disappeared after 3-5 d of treatment with antimicrobial agent. Bone union was observed in all patients in a mean of 6 weeks (range 5-7 weeks). The time to return to work was (31.6±8.9) d after the surgical treatment of the fracture. Conclusions Mini-plate and screws fixation of unstable metacarpal fractures produces anatomical reduction of fractures with stabilization that is rigid enough to allow early mobilization, thereby preventing stiffness and hence good functional results.

Protruded and nonprotruded subungual exostosis: Differences in surgical approach.

Background: In subungual exostosis surgery, repair of the damaged nail bed and surgical excision of the mass without damaging the nail bed is important. The ideal method of surgery is still unclear. This study is done to qualify the effects of different surgical methods on outcome measures in different types of subungual exostosis. Materials and Methods: Fifteen patients, operated with a diagnosis of subungual exostosis between January 2008 and June 2012, were evaluated. Protruded masses were excised with a dorsal surgical approach after the removal of the nail bed and nonprotruded masses were excised through a“fish-mouth” type of incision. Results: The mean age of the patients in protruded subungual exostosis group was 17.3 years (range 13-22 years) and this group consisting of seven female and two male patients. The patients were followed up for a mean of 14.1 ± 4.8 months. The mean age of the patients in the nonprotruded subungual exostosis group was 14.6 years (range 13-16 years) and consisting of six female patients. The patients were followed up for a mean of 11.6 ± 2.9 months. The results were positively affected by changing the surgical approach depending on whether or not the exostosis is protruded from the nail bed. All patients had healthy toe nails in the postoperative period without any signs of recurrence. Conclusions: In patients with a protruded subungual exostosis, the mass should be removed by a dorsal approach with the removal of the nail and injury to the nail bed should be repaired. In patients with a nonprotruded subungual exostosis, the mass should be excised through a “fish-mouth” type incision at the toe tip without an iatrogenic damage.

MODIFIED BRUNELLI PULL-OUT SUTURE TECHNIQUE IN ZONE II FLEXOR TENDON RUPTURE: A FRESH HUMAN CADAVER STUDY

PURPOSE The aim of our study is to develop a suture technique that has sufficient strength of active mobilization. METHODS Thirty two fingers of six fresh human cadavers were divided into two groups. Flexor digitorum profundus (FDP) tendons in the study group were repaired by modified Brunelli suture technique and modified Kessler suture technique, while those in the control group were repaired by Modified Kessler suture technique. Flexion and extension movements were performed with 10 N of load, increasing 1 N at a time to the tendons in both groups. Rupture and significant gap formation was evaluated up to 20 N of load. In the study, to evaluate the resistance to active motion, 1000 times flexion and extension motion cycle was performed with a load of 20 N. The succeeding repaired tendons was also tested with flexion and extension movements increasing the load 1 N at a time. RESULTS In the study group, failure and significant gap formation on the repair zone were not observed after 20 N of load and 1000 times cyclic flexion and extension movements for resisting to active motion. The rupture and significant gap formation was observed on a average load of 98.43 ± 0.47 N. In the Modified Kessler suture technique, on the eight tendons before reaching the 20 N of load for resisting to active motion, and the remaining eight tendons, during the 20 N loaded motion cycle essential for active motion, rupture and significant gap formation was observed. The failure and significant gap formation was observed on a average load of 18.37 ± 1.89 N. It is measured that by accompanying Modified Brunelli suture to the Modified Kessler suture technique, the resistance was increased up to 5-6 times. DISCUSSION By the Modified Brunelli suture technique, active motion can be started to the finger without a dorsal block sling immediately after the surgery. Clinical Relavans: By the modified technique, the rehabilitation difficulty and joint stiffness will be minimized.

Osteoid osteoma of distal phalanx of toe: a rare cause of foot pain.

Osteoid osteoma is an uncommon benign tumor and causes severe pain, being worse at night, that responds dramatically to nonsteroidal anti-inflammatory medications. An osteoid osteoma of the toe is very rare and arising in a pedal phalanx may be difficult to diagnose. A 34-year-old male has local swelling and tenderness but there were no hyperemia, temperature increase, or clubbing. There was a 2-month history of antibiotic treatment with suspicion of soft tissue infection in another clinic. The osteoid osteoma was completely excised by curettage and nidus removal with open surgical technique. The patient was followed up for 63 months with annual clinical and radiographic evaluations. There was no relapse of the pain and no residual recurrent tumour. Osteoid osteoma may be difficult to distinguish from chronic infection or myxedema. The patients may be taken for unnecessary treatment. The aim of the treatment for osteoid osteoma is to remove entire nidus by open surgical excision or by percutaneous procedures such as percutaneous radiofrequency and laser ablation. Osteoid osteomas having radiologic and clinical features other than classical presentation of osteoid osteoma are called atypical osteoid osteomas. Atypical localized osteoid osteomas can be easily misdiagnosed and treatment is often complicated.