Halil Ibrahim Balci

Fixator-Assisted Acute Femoral Deformity Correction and Consecutive Lengthening Over an Intramedullary Nail

BACKGROUND External fixators are being used frequently in standard limb-lengthening and deformity-correction procedures. Lengthening over an intramedullary nail has been a successful technique, and fixator-assisted intramedullary nailing has provided satisfactory results for the correction of selected deformities. We report a combined technique for the treatment of femoral deformities associated with shortening. METHODS Between 1997 and 2005, twenty-eight femora in twenty-five patients with a median age of twenty-seven years underwent reconstruction with an intramedullary nail and a unilateral fixator. The mean amount of shortening was 6.33 cm, and the mean preoperative mechanical axis deviation was 33.86 mm. Deformity correction was performed acutely and secured by the intramedullary nail, which was locked distally, and the same external fixator that was used for the deformity correction was utilized for lengthening. At the end of the distraction period, proximal locking screws were placed in the intramedullary nail and the external fixator was removed. At the time of follow-up, deformity correction and bone healing were assessed clinically and radiographically, complications were noted, and the functional results were assessed. RESULTS The mean duration of follow-up was forty months. The mean duration of the external fixation was 83.29 days, and the mean external fixation index was 14.98 days/cm. The mean amount of lengthening was 6.02 cm. The mean amount of mechanical axis deviation at the end of the treatment was 11.29 mm. The mean bone healing index was 36.66 days/cm. A knee flexion contracture developed in one patient and resolved after intensive rehabilitation. One patient underwent two revisions because of Schanz screw displacement secondary to cortical fracture, and four patients with minor pin-track infections were treated successfully with local wound care and oral antibiotics. CONCLUSIONS While femoral lengthening and deformity correction can be obtained with classic methods for application of an external fixator, the long period of external fixation, patient discomfort, and plastic deformation of the regenerated bone after removal of the fixator are major disadvantages. Two techniques, fixator-assisted nailing and lengthening over an intramedullary nail, were combined in this series. The duration of the external fixation was reduced compared with that required for classic treatment with an external fixator and patient comfort was increased. In addition, the intramedullary nail prevented fracture and deformation of the regenerated bone.

Evaluation of Needle Positioning During Blind Intra-Articular Hip Injections for Osteoarthritis: Fluoroscopy Versus Arthrography

UNLABELLED Diraçoğlu D, Alptekin K, Dikici F, Balci HI, Ozçakar L, Aksoy C. Evaluation of needle positioning during blind intra-articular hip injections for osteoarthritis: fluoroscopy versus arthrography. OBJECTIVE To evaluate needle positioning during blind/anatomically referenced hip joint injections for osteoarthritis (OA). DESIGN Experimental clinical study. SETTING Operating theater of a university hospital. PARTICIPANTS Patients (N=16) (10 women, 6 men), who were diagnosed as having OA according to the American College of Rheumatology criteria and whose radiologic grades were II or III according to Kellgren-Lawrence. INTERVENTIONS Three bilateral and 13 unilateral hip injections were performed (3 times at 1-week intervals). After it was presumed blindly that the needle was within the joint, the location of the needle was checked with backflow technique and fluoroscopy. Entrance to the joint cavity was also ensured by reconfirmation with contrast medium, and the procedure was then terminated with hyaluronic acid injection. MAIN OUTCOME MEASURES Assessment of blind needle placement into the hip joint by using backflow technique, fluoroscopic images, and contrast enhancement. RESULTS The location of the needle was fluoroscopically confirmed to be at the proper position in 38 (66.7%) of the 57 blind interventions. Furthermore, in 29 (76.3%) of those 38 interventions, localization of the intra-articular needle could be confirmed by intra-articular contrast uptake. Overall, 29 of 57 (50.9%) blind interventions exhibited intra-articular contrast enhancement. Backflow was not observed in 23 (79.3%) of these 29 interventions. Five (17.9%) of 28 interventions with no contrast uptake showed backflow. CONCLUSIONS In light of our results, we suggest that blind injection of the osteoarthritic hip joint can be inaccurate even with careful technique. Further, the backflow method does not appear to be reliable, and guidance during the injection seems to be necessary.

Fixator-assisted nailing and consecutive lengthening over an intramedullary nail for the correction of tibial deformity

We report the results of using a combination of fixator-assisted nailing with lengthening over an intramedullary nail in patients with tibial deformity and shortening. Between 1997 and 2007, 13 tibiae in nine patients with a mean age of 25.4 years (17 to 34) were treated with a unilateral external fixator for acute correction of deformity, followed by lengthening over an intramedullary nail with a circular external fixator applied at the same operating session. At the end of the distraction period locking screws were inserted through the intramedullary nail and the external fixator was removed. The mean amount of lengthening was 5.9 cm (2 to 8). The mean time of external fixation was 90 days (38 to 265). The mean external fixation index was 15.8 days/cm (8.9 to 33.1) and the mean bone healing index was 38 days/cm (30 to 60). One patient developed an equinus deformity which responded to stretching and bracing. Another developed a drop foot due to a compartment syndrome, which was treated by fasciotomy. It recovered in three months. Two patients required bone grafting for poor callus formation. We conclude that the combination of fixator-assisted nailing with lengthening over an intramedullary nail can reduce the overall external fixation time and prevent fractures and deformity of the regenerated bone.

Combined technique for the correction of lower-limb deformities resulting from metabolic bone disease

We present the results of the surgical correction of lower-limb deformities caused by metabolic bone disease. Our series consisted of 17 patients with a diagnosis of hypophosphataemic rickets and two with renal osteodystrophy; their mean age was 25.6 years (14 to 57). In all, 43 lower-limb segments (27 femora and 16 tibiae) were osteotomised and the deformity corrected using a monolateral external fixator. The segment was then stabilised with locked intramedullary nailing. In addition, six femora in three patients were subsequently lengthened by distraction osteogenesis. The mean follow-up was 60 months (18 to 120). The frontal alignment parameters (the mechanical axis deviation, the lateral distal femoral angle and the medial proximal tibial angle) and the sagittal alignment parameters (the posterior distal femoral angle and the posterior proximal tibial angle) improved post-operatively. The external fixator was removed either at the end of surgery or at the end of the lengthening period, allowing for early mobilisation and weight-bearing. We encountered five problems and four obstacles in the programme of treatment. The use of intramedullary nails prevented recurrence of deformity and refracture.

Hip fractures in patients older than 75 years old: Retrospective analysis for prognostic factors

BACKGROUND Proximal femoral fractures are often seen in older patients and are associated with high mortality. Introduction to old age population is latening due to advancements in medical sciences and increasing life expectancy. OBJECTIVES The aim of the study was to evaluate factors affecting mortality in patients above 75 years of age who had been operated because of proximal femur fractures. PATIENTS AND METHODS Patients with age 75 and over who suffers from post-fall proximal femoral fracture who underwent surgery with one of following three methods (hemiarthroplasty, proximal femoral nail or total hip arthroplasty) were evaluated retrospectively. Effects on mortality were examined for factors such as type of surgery, type of anesthesia, preoperative ASA score (American Society of Anesthesiologists Score), need for intensive care, need for blood transfusion, operation waiting time and hospitalization duration. 115 patients who met inclusion criterion were included in the study out of 224 overall. 75 patients were women and 40 were males. RESULTS Mortality rate after first year was found to be 40%. Patients over 85 years old had higher rates of mortality (p = 0,0003) than respectively younger patients (75-85). Sex was found to have no impact on mortality (p = 0.5039). There was no statistically significant difference in terms ASA score (p = 0.1518). Order of applied surgical methods with mortality risk rates was found to be total hip arthroplasty > hemiarthroplasty > proximal femoral nail (p = 0.0003). Type of anesthesia, the use of cement during arthroplasty, operation waiting time and hospitalization duration was not directly related with mortality rate (type of anesthesia p = 0.63, the use of cement during arthroplasty p = 0.223, operation waiting time p = 0.5 and hospitalization duration p = 0.19). CONCLUSIONS Age is the primary risk factor on first year mortality in patients older than 75 years old with hip fractures. Addition to older age, more need to blood transfusions, and arthroplasty are other risk factors for first year mortality. It should be kept in mind that after 75 years old first year mortality may be higher if the patient is treated with arthroplasty.

Knee flexion contracture in haemophilia: treatment with circular external fixator.

Haemophilia, a bleeding disorder, causes recurrent intra‐articular bleeding of the joints result‐ing in chronic haemophilic arthropathy with fixed knee flexion deformity. Mid‐long‐term results (between 2002 and 2006) of deformity correction in haemophilic patients with Ilizarov type circular external fixators were retrospectively evaluated. There were six patients (five haemophilia A and one haemophilia B). The mean age was 14.7 years (range, 8–22 years) at the time of initial surgery. The mean knee flexion contracture was 45 degrees (range, 30–75 degrees). The mean arc of motion was 58.3 degrees (range, 40–100) before the surgery. The mean duration of follow‐up was 8 years (range, 5.5–10 years). The mean duration of external fixation was 4.4 months (range, 2.5–10.5 months). Full extension of the knee joint was obtained in all patients in the early postoperative period. No bleeding, neurological or vascular complications were encountered. The mean amount of recurrence in knee flexion contracture was 10 degrees (range, 0–15 degrees). The amount of the correction was significant (P = 0.0012) and the mean arc of motion was 51.6 degrees (range, 25–90 degrees) that show a decrease of 6.7 degrees (P = 0.04) at the end of follow‐up. The circular external fixator is an important, safe and less invasive alternative surgical treatment modality with low recurrence rate. Using the external hinges and distraction during the correction has a protective effect on the joint. It requires a team‐work consisting of a haematologist, an orthopaedic surgeon and a physical therapist.

Bilateral humeral lengthening in achondroplasia with unilateral external fixators: is it safe and does it improve daily life?

A retrospective study was performed in 18 patients with achondroplasia, who underwent bilateral humeral lengthening between 2001 and 2013, using monorail external fixators. The mean age was ten years (six to 15) and the mean follow-up was 40 months (12 to 104). The mean disabilities of the arm, shoulder and hand (DASH) score fell from 32.3 (20 to 40) pre-operatively to 9.4 (6 to 14) post-operatively (p = 0.037). A mean lengthening of 60% (40% to 95%) was required to reach the goal of independent perineal hygiene. One patient developed early consolidation, and fractures occurred in the regenerate bone of four humeri in three patients. There were three transient radial nerve palsies. Humeral lengthening increases the independence of people with achondroplasia and is not just a cosmetic procedure.

Can Normal Fracture Healing Be Achieved When the Implant Is Retained on the Basis of Infection? An Experimental Animal Model

BackgroundInfection after open fractures is a common complication. Treatment options for infections developed after intramedullary nailing surgery remain a topic of controversy. We therefore used a rat fracture model to evaluate the effects of infection on osseous union when the implant was maintained.Questions/purposesIn a rat model, (1) does infection alter callus strength; (2) does infection alter the radiographic appearance of callus; and (3) does infection alter the histological properties of callus?MethodsAn open femoral fracture was created and fixed with an intramedullary Kirschner wire in 72 adult male Sprague-Dawley rats, which were divided into two study groups. In the infection group, the fracture site was contaminated with Staphylococcus aureus (36 animals), whereas in the control group, there was no bacterial contamination (36 animals). No antibiotics were used either for prophylaxis or for treatment. We performed biomechanical (maximum torque causing failure and stiffness), radiographic (Lane and Sandhu scoring for callus formation), and histologic (scoring for callus maturity) assessments at 3 and 6 weeks. The number of bacteria colonies on the femur, wire, and soft tissue inside knee were compared to validate that we successfully created an infection model. The number of bacteria colonies in the soft tissue inside the knee was higher in the infection group after 6 weeks than after the third week, demonstrating the presence of locally aggressive infection.ResultsInfection decreased callus strength at 6 weeks. Torque to failure (299.07 ± 65.53 Nmm versus 107.20 ± 88.81, mean difference with 95% confidence interval, 192 [43–340]; p = 0.007) and stiffness at 6 weeks (11.28 ± 2.67 Nmm versus 2.03 ± 1.68, mean difference with 95% confidence interval, 9 [3–16]; p = 0.004) both were greater in the control group than in the group with infection. Radiographic analysis at 6 weeks demonstrated the fracture line was less distinct (Lane and Sandhu score of 2–3) in the infection group and complete union was observed (Lane and Sandhu score of 3–4) in the control group (p = 0.001). Semiquantitative histology scores were not different between the noninfected controls and the rats with infection (score 10 versus 9).ConclusionsRetaining an implant in the presence of an underlying infection without antibiotic treatment leads to weaker callus and impedes callus maturation compared with noninfected controls in a rat model. Future studies might evaluate whether antibiotic treatment would modify this result.Clinical RelevanceThis model sets the stage for further investigations that might study the influence of different interventions on fracture healing in implant-associated osteomyelitis. Future observational studies might also evaluate the histological properties of callus in patients with osteomyelitis.

Treatment of infected nonunion of the juxta-articular region of the distal tibia

OBJECTIVE The purpose of this study was to summarize our clinical results with distraction osteogenesis for the treatment of infected tibial nonunion around the ankle joint. METHODS Between 1994 and 2009, 13 patients with a mean age of 50 years (range: 27-79 years) underwent tibial reconstruction for the treatment of infected nonunion of the distal tibia, with a mean bone loss of 4.8 cm (range: 1-7 cm). Lengthening over an intramedullary nail as a second procedure was used in 2 patients, bifocal compression and distraction technique in 5 cases, compression with Ilizarov external fixator in 5 cases, and Taylor Spatial Frame (TSF, Smith Nephew, Memphis, TN, USA) in 1 case. At final follow-up, functional and radiographic results were evaluated according to Paleys bone and functional healing criteria. RESULTS Mean duration of follow-up was 36 months. Mean external fixation time was 198 days, and mean external fixation index was 29 days/cm. According to Paleys bone healing criteria, there were 10 excellent, 2 good, and 1 poor result(s); additionally, according to Paleys functional healing criteria, there were 5 excellent, 6 good, and 2 fair results. There were 11 problems, 5 obstacles, and 1 sequel according to Paleys classification of complications. There was 1 persisting nonunion, which underwent revision with a retrograde intramedullary nail. CONCLUSION External fixator and/or combined treatment are effective and reliable methods to treat infected nonunion of the distal tibia. Every patient should be evaluated according to their infection level and bony defects for reconstruction.

Simultaneous bilateral lengthening of femora and tibiae in achondroplastic patients

OBJECTIVE The aim of this study was to analyze the results and complications of simultaneous bilateral femoral and tibial lengthening in achondroplastic patients. METHODS The study included the 44 femora and 44 tibiae of 22 achondroplastic patients (16 females, 6 males; mean age: 6.36 years, range: 3 to 11 years) that underwent simultaneous lengthening. Orthofix LRS monolateral fixators were used for femoral lengthening and either Ilizarov-type or hexapod-type circular external fixators for tibial lengthening. Tenotomies of the hip flexors and the Achilles tendon were performed to prevent injury to the growth plates and to prevent joint contractures. Results and complications were evaluated according to Paleys scoring and complication systems. RESULTS Average follow-up time was 35 (range: 26 to 76) months. The femora were lengthened by an average of 7.07 cm (46.1%), and the tibiae by an average of 6.64 cm (52.9%). Patients gained an average of 16.9 cm in height, including physiological growth. The mean bone-healing index (BHI) was 31.2 days/cm for the femora (range: 17.4 to 43.3 days/cm) and 34.3 days/cm for the tibiae (range: 19.5 to 60.0 days/cm). Complications included 3 delayed maturations, 3 pin track infections, 5 transient fibular paralyses, 5 regenerate fractures, 1 late varus deformity, 1 knee contracture and 1 knee contracture secondary to knee dislocation. Functional scores were excellent in 78 segments, good in 8, fair in 1 and poor in one. There was no growth inhibition related to the lengthening. CONCLUSION Bilateral simultaneous lengthening of the femora and tibiae in achondroplastic patients provided a reduction in total treatment and external fixation time, with a low rate of complications.