Kaan Erler

Treatment of tibial bone defects with the Ilizarov circular external fixator in high-velocity gunshot wounds

Summary. One of the applications for circular external fixators is the treatment of large-bone defects which may be difficult to manage with conventional methods. Successful results have been reported with the use of circular external fixators, particularly in the treatment of infected tibial pseudoarthroses and those with bone loss. In this study, a total of 43 cases with tibial bone defects (18 infected) as a result of high-velocity gun-shot injuries were treated with circular external fixators between January 1, 1988 and December 31, 1995. The mean follow-up period was 50 months (range: 28–98 months) after the removal of the Ilizarov device. Satisfactory union was obtained in 40 cases without any major complication or additional surgical intervention, in spite of the large and in some cases infected defects. We conclude that this is a safe method for the treatment of infected or noninfected tibial bone defects.Résumé. Une des applications des fixateurs externes circulaires (FEC) est le traitement des pertes de substance osseuse qu’on ne peut pas traiter facilement avec les méthodes classiques. Des auteurs rapportent les résultats de traitement dans des cas de pseudarthrose infectée du tibia. Ils rapportent les résultats de 48 perte de substance du tibia secondaire à des blessures par arme à feu. 18 d’entre-eux étaient infectés. Le délai d’observation moyen était de 50 mois (28–98 mois) après ablation de l’appareil d’Ilizarov. Dans 40 cas, il n’y as pas eu de complication majeure ni de nécessité d’intervention chirurgicale complémentaire. En conclusion, c’est une bonne méthode pour traiter les pertes de substance osseuse du tibia infecté ou non.

Bilateral femoral insuffiency fractures treated with inflatable intramedullary nails: a case report

Stress fractures could be classified as fatigue fractures and insufficiency fractures (IF). Fatigue fractures occur when abnormal mechanical stress is applied to a normal bone, on the other hand insufficiency fractures occur when normal to moderate pressure is applied to a bone that has decreased resistance (Daffner and Pavlov in Am J Radiol 159:242–245, 1992). IF have been observed mainly in patients with postmenopausal osteoporosis, and are becoming more common with the increase of elderly population (Daffner and Pavlov in Am J Radiol 159:242–245, 1992). Other systemic and metabolic conditions that can result in osteopenia and IF include osteomalacia, hyperparathyroidism, hyperthyroidism, rheumatoid arthritis, fluoride treatment, diabetes mellitus, fibrous dysplasia, Paget’s disease, irradiation and mechanical factors (Daffner and Pavlov in Am J Radiol 159:242–245, 1992; Soubrier et al. in Joint Bone Spine 70:209–218, 2003; Epps et al. in Am J Orthop 33:457–460, 2004; Austin and Chrissos in Orthopedics 28:795–797, 2005). In this case report, the authors present an osteoporotic woman who developed bilateral insufficiency fracture of the femoral shaft after longstanding steroid, thyroxine replacement and alendronate therapy due to partial empty sella syndrome and osteoporosis, resulting in the treatment of the fracture by inflatable intramedullary nailing.

Bilateral lower limb amputations as a result of landmine injuries

Landmine explosions cause most of the war injuries in the battlefield. Amputations resulting from severe injuries reveal serious problems despite the improvements in surgery. Bilateral lower limb amputations have more impact than unilateral on social life. Some 29 cases with lower limb amputations due to landmine injuries were treated in the Department of Orthopaedics and Traumatology, Gülhane Military Medical Academy between January 1992 and December 1996. Amputation levels were as follows: 1 case had hip disarticulation and a trans-femoral amputation, 6 had bilateral trans-femoral amputations, 6 had trans-femoral and trans-tibial amputations, 12 had bilateral trans-tibial amputations, 1 had trans-femoral and Chopart amputations and the remaining 3 cases had trans-tibial and Chopart amputations. The initial treatment was done for all cases in the first 6–8 hours after injury at the field hospitals. Aggressive debridement, excision and primary closure were performed. None of the stumps required reamputations and/or revision. No case had gas gangrene or tetanus. Postoperative, pre-prosthetic training programme which ranged between 30–120 days with an average 48 days; and prosthesis fitting and adequate post-prosthetic training programme which ranged 32–126 (average 94) days was applied. All the cases were followed-up with a mean of 38.5 months (14–72 months). Nine (9) cases (31%) returned to their previous occupation, while 20 (69%) cases had to change their jobs.

Benign bone tumors in children.

When children present for evaluation of bone tumor, great anxiety often occurs among the family. Usually the diagnosis of a benign bone tumor can be made easily with plain radiographs without biopsy. Most have a good outcome. However, occasionally, serious complications can develop. Moreover, the physician must be aware of the possibility of the malignant tumors. To avoid errors in the evaluation and treatment of this heterogeneous group of tumors, the clinician should have a good knowledge base of common bone neoplasms and correlate the clinical, radiographic, and pathologic findings. In this article, history, diagnosis, evaluation, treatment, and management of common types of benign tumors of bone commonly seen in children and adolescents are reviewed in the light of current literature.

Ankle swelling in a 6-year-old boy with unusual presentation: Report of a rare case☆☆☆★★★♢♢♢♦

A 6-year-old boy with a history of pain and swelling in the right ankle was referred to our medical center. A cascading algorithm helped us to better evaluate this case of an osteochondroma of talus. The diagnosis was based on clinical and radiologic findings and on histopathologic analysis of the excised tissue. Although osteochondroma, or osteocartilaginous exostosis, is a common skeletal neoplasm, it is rarely seen in the foot. The rare location, a young age group, and an inexperienced surgeon may make the diagnosis confusing. We presented a case that shows the importance of an orderly evaluation of a musculoskeletal neoplasm. This may be helpful for the physician to better understand the clinical implications of any case before attempting a surgical intervention.

Does false aneurysm behave like a sarcoma? Distal femoral arterial false aneurysm simulated a malign mesenchymal tumor

We report a case of a pseudo-aneurysm of the distal femoral artery presenting as a malignant mesenchymal tumor with insidious onset, progressive symptoms, large volume mass, and atypical radiological findings.

Treatment of Complex Calcaneal Fractures with Bony Defects from Land Mine Blast Injuries with a Circular External Fixator

Four calcanei, which were massively destroyed as a result of blasting injuries from land mines, and 18 severely comminuted calcaneal fractures with bony defects (in one patient, both feet), also from land mines, were treated using a circular external fixator for reconstruction by osteogenic distraction. Because of the severe destruction of tissue to be treated, definitive orthopaedic treatment was delayed for 3 to 28 months (average, 10.1 months) after injury. Time from first use of the circular external fixator to removal of the apparatus ranged from 110 to 175 days (average, 143.7 days). Mean follow-up was 18 months. Of the 22 calcaneal injuries, 4 had excellent results, 11 good, 5 fair, and 2 had poor results. Better results were achieved in cases with lesser defects in bone and where definitive orthopaedic treatment was delayed until problems in soft tissue could be treated.

Pins and Rubber Band Traction for Treatment of Comminuted Intra-Articular Fractures in the Hand

PURPOSE To determine the efficacy of pins and rubber band traction for treatment of comminuted intra-articular fractures in the hand. METHODS We performed a retrospective study from 1994 to 2013 to evaluate 33 patients in whom pins and rubber band traction was employed. We clinically evaluated the active range of motion of the affected fingers after surgery. Eleven of the 33 fractures were at the proximal interphalangeal joint, 10 at the distal interphalangeal joint, 5 at the thumb interphalangeal joint, and 2 at the metacarpophalangeal joint of the thumb. The remaining 5 patients had complex fracture-dislocation of the proximal interphalangeal joints. RESULTS The mean follow-up period was 24 months. The average active motion of the metacarpophalangeal joints of the fingers was 91° (range, extension 0°-10°/flexion 85°-90°), proximal interphalangeal joints was 92° (range, extension/flexion 0°-10°/85°-100°), and distal interphalangeal joints was 73° (range, extension/flexion 0°-10°/60°-80°). The overall average of all active motion of the injured fingers except thumbs was 255° (range, 240°-270°). The average active motion of the of the thumb metacarpophalangeal joint was 56° (range, extension 5°-10°/flexion 50°-55°), and interphalangeal joint was 74° (range, extension 0°-10°/flexion 75°-80°). The average of active motion of the injured thumb metacarpal and interphalangeal joints combined was 130° (range, 125°-135°). CONCLUSIONS Pins and rubber band traction is a treatment option for comminuted displaced intra-articular fractures of the digits that offers satisfactory clinical results. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Prospective Study of Percutaneous Radiofrequency Nerve Ablation for Chronic Plantar Fasciitis

Background: Chronic plantar heel pain is one of the most painful foot conditions and is generally associated with plantar fasciitis. This study reports 2-year follow-up results of radiofrequency nerve ablation (RFNA) of the calcaneal branches of the inferior calcaneal nerve in patients with chronic heel pain associated with plantar fasciitis. Methods: After receiving approval from the institutional review board, we prospectively evaluated the results of the RFNA of the calcaneal branches of the inferior calcaneal nerve on 35 feet in 29 patients with plantar heel pain between 2008 and 2011. All of the patients who were treated had been complaining of heel pain for more than 6 months and had failed conservative treatment. All of the patients were evaluated (quantitatively) using the average 10-point Visual Analog Scale (VAS) before treatment, as well as at their 1-month, 1-year, and 2-year follow-up after the procedure. We also evaluated 26 feet in 20 patients with American Orthopaedic Foot and Ankle Society scale (AOFAS) scores before the treatment, as well as at their 1-month, 1-year, and 2-year follow-up after the procedure. Results: The average VAS score of the feet was 9.2 ± 1.9 before treatment, 0.5 ± 1.3 at 1 month after the procedure, 1.5 ± 2.1 at 1-year follow-up, and 1.3 ± 1.8 at 2-year follow-up (P < .001). The average AOFAS scores of the patients were 66.9 ± 8.1 (range, 44-80) before treatment, 95.2 ± 6.1 (range, 77-100) at 1 month after the procedure, 93 ± 7.5 (range, 71-100) at the 1-year follow-up, and 93.3 ± 7.9 (range, 69-100) at the 2-year follow-up. At the 1- and 2-year follow-up, 85.7% of the patients rated their treatment as very successful or successful. Conclusion: These findings suggest that RFNA of the calcaneal branches of the inferior calcaneal nerve was an effective pain treatment option for chronic heel pain associated with plantar fasciitis that did not respond to other conservative treatment options. Level of Evidence: Level IV, retrospective case series.

Acute traumatic open posterolateral dislocation of the ankle without tearing of the tibiofibular syndesmosis ligaments: a case report.

Pure open dislocation of the ankle, or dislocation not accompanied by rupture of the tibiofibular syndesmosis ligaments or fractures of the malleoli or of the posterior border of the tibia, is an extremely rare injury. A 62-year-old man injured his right ankle in a motor vehicle accident. Besides posterolateral ankle dislocation, there was a 7-cm transverse skin cut on the medial malleolus, and the distal end of the tibia was exposed. After reduction, we made a 2- to 2.5-cm longitudinal incision on the lateral malleolus; the distal fibular fracture was exposed. Two Kirschner wires were placed intramedullary in a retrograde manner, and the fracture was stabilized. The deltoid ligament and the medial capsule were repaired. The tibiofibular syndesmosis ligaments were intact. At the end of postoperative year 1, right ankle joint range of motion had a limit of approximately 5 degrees in dorsiflexion, 10 degrees in plantarflexion, 5 degrees in inversion, and 0 degrees in eversion. The joint appeared normal on radiographs, with no signs of osteoarthritis or calcification. The best result can be obtained with early reduction, debridement, medial capsule and deltoid ligament restoration, and early rehabilitation. Clinical and radiographic features at long-term follow-up also confirm good mobility of the ankle without degenerative change or mechanical instability.