Kerem Bilsel

Reconstruction of Segmental Bone Defects Due to Chronic Osteomyelitis with Use of an External Fixator and an Intramedullary Nail

BACKGROUND Callus distraction over an intramedullary nail is a rarely used technique for the reconstruction of intercalary defects of the femur and tibia after radical débridement of chronic osteomyelitic foci. The aim of this study was to summarize our experience with distraction osteogenesis performed with an external fixator combined with an intramedullary nail for the treatment of bone defects and limb-shortening resulting from radical débridement of chronic osteomyelitis. METHODS Thirteen patients who ranged in age from eighteen to sixty-three years underwent radical débridement to treat a nonunion associated with chronic osteomyelitis of the tibia (seven patients) and femur (six patients). The lesions were classified, according to the Cierny-Mader classification system, as type IVA (nine) and type IVB (four). The resulting segmental defects and any limb-length discrepancy were then reconstructed with use of distraction osteogenesis over an intramedullary nail. Two patients required a local gastrocnemius flap. Free nonvascularized fibular grafts were added to the distraction site for augmentation of a femoral defect at the time of external fixator removal and locking of the nail in two patients. At the time of the latest follow-up, functional and radiographic results were evaluated with use of the criteria of Paley et al. RESULTS The mean size of the defect was 10 cm (range, 6 to 13 cm) in the femur and 7 cm (range, 5 to 10 cm) in the tibia. The mean external fixator index was 13.5 days per centimeter, the consolidation index was 31.7 days/cm, and the mean time to union at the docking site was nine months (range, five to sixteen months). At a mean follow-up of 47.3 months, eleven of the thirteen patients had an excellent result in terms of both bone and functional assessment. There were two recurrences of infection necessitating nail removal. These patients underwent revision with an Ilizarov fixator. Subsequently, the infection was controlled and the nonunions healed. CONCLUSIONS This combined method may prove to be an improvement on the classic techniques for the treatment of a nonunion of a long bone associated with chronic osteomyelitis, in terms of external fixation period and consolidation index. The earlier removal of the external fixator is associated with increased patient comfort, a decreased complication rate, and a convenient and rapid rehabilitation.

Biomechanical Comparison of Fixation Techniques in Midshaft Clavicular Fractures

Objectives: The purpose of this study is to evaluate the biomechanical properties and the stability among a locking clavicle plate (LCP), a dynamic compression plate (DCP) and an external fixator (Ex-fix) in an unstable displaced clavicle fracture model under torsional and three-point bending loading. Materials and Methods: Forty-eight human adult formalin-fixed clavicles were paired according to their bone mineral density homogeneously into three groups: LCP, DCP, and Ex-fix. Each specimen was osteotomized at the midshaft. Torsional and three-point bending forces were performed for 1000 cycles with stiffness recorded at 10 cycles (initial) and then at 100-cycle intervals thereafter. Initial stiffness, failure loads, and the percentage of initial stiffness at the various intervals were compared using analysis of variance. Results: The mean initial stiffness values (Nmm/deg) for torsion were 703.2 (LCP), 448.1 (DCP), and 365.2 (Ex-fix). The mean failure moments (Nmm) for torsion were 7671.7 (LCP), 4370.3 (DCP), and 2999.7 (Ex-fix). The mean initial stiffness (Nmm) for bending were 32.6 (LCP), 23.4 (DCP), and 20.6 (Ex-fix). The mean failure loads (N) for bending were 213.2 (LCP), 131.1 (DCP), and 102.7 (Ex-fix). For both torsion and bending, an overall significant difference among the three constructs in terms of failure loads and also a significant difference between the locking plate and the other two models only in terms of initial stiffness was seen. For torsion and bending, at all cyclic intervals, there was a significant difference between the locking plate and the other two models. After 700 cycles, a significant difference was also detected between the DCP and Ex-fix in torsion, but no difference was found between these groups at any cyclic interval in bending. Conclusions: The locking plate is significantly more stable than DCP and Ex-fix under torsional and bending cyclic loading in a displaced fracture clavicle model.

Does Obesity Negatively Affect the Functional Results of Arthroscopic Partial Meniscectomy? A Retrospective Cohort Study

PURPOSE The purpose of this study was to evaluate the impact of body mass index (BMI) on early functional results of patients who undergo isolated partial meniscectomy. METHODS The functional results for 1,090 patients who underwent partial meniscectomy, in 2 different orthopaedic clinics, were evaluated retrospectively. The study includes cases with arthroscopic partial meniscectomy for isolated meniscal tears; patients with concomitant knee pathology were excluded. Three hundred forty-one (31%) patients with isolated lateral meniscal tears, 628 (58%) patients with isolated medial meniscal tears, and 121 (11%) patients with both medial and lateral meniscal tears underwent arthroscopic partial meniscectomy. We divided these patients into 3 subgroups on the basis of their BMI; <26, between 26 and 30, ≥30. Preoperative functional results were compared with 1-year postoperative follow-up results using the International Knee Documentation Committee (IKDC),(26) Lysholm Knee Scale,(27) and Oxford Scoring System(28) scores. RESULTS According to all 3 knee scales, age, side of lesion, and tear type had no effect on functional outcome. When compared with the group with BMI <26, the patients with BMI between 26 and 30 and the patients with BMI ≥30 had significantly worse outcomes as measured by the IKDC, Oxford Scoring System, and Lysholm Knee Scale scores. Patients with BMI between 26 and 30 and ≥30 did not have significantly different functional outcomes. CONCLUSIONS Short-term outcomes after arthroscopic partial menisectomy reflect significant improvement in subjective outcome. However, patients with moderate or significant obesity (BMI >26) have inferior short-term outcomes compared with nonobese patients. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Comparison of arthrodesis, resurfacing hemiarthroplasty, and total joint replacement in the treatment of advanced hallux rigidus

The purpose of the present study was to compare the functional results of arthrodesis, resurfacing hemiarthroplasty, and total joint replacement in hallux rigidus. The data from patients treated from 2006 to 2010 for advanced stage hallux rigidus were retrospectively reviewed. A total of 38 patients who had at least 2 years (range 24 to 66 months, mean 31.1) of follow-up were included in the present study. Of the 38 patients, 12 were included in the total joint replacement group (group A), 14 in the resurfacing hemiarthroplasty group (group B), and 12 in the arthrodesis group (group C). At the last follow-up visit, the functional outcomes were evaluated using the American Orthopaedic Foot and Ankle Society-Hallux Metatarsophalangeal Interphalangeal (AOFAS-HMI) scale, visual analog scale (VAS), and metatarsophalangeal range of motion. Significant improvements were seen in the AOFAS-HMI score, with a decrease in the VAS score in all 3 groups. According to the AOFAS-HMI score, no significant difference was found between groups A and B. However, in group C, the AOFAS-HMI scores were significantly lower than in the other groups owing to the lack of motion. According to the final VAS scores, no significant difference was found between groups A and B; however, the VAS score had decreased significantly more in group C than in the other groups. No major complications occurred in any of the 3 groups. After 2 years of follow-up, all the groups had good functional outcomes. Although arthrodesis is still the most reliable procedure, implant arthroplasty is also a good alternative for advanced stage hallux rigidus.

Comparison of Three Different Treatment Modalities in the Management of Humeral Shaft Nonunions (Plates, Unilateral, and Circular External Fixators)

Objectives: To compare 3 different fixation methods for the treatment of humeral shaft nonunions in terms of union time, functional outcome, and complications. Design: Retrospective case series. Setting: University hospital. Patients: Between 1996 and 2004, 80 patients (mean age, 49; range, 15 to 86; 30 women and 50 men) with nonunions of the humeral shaft were treated surgically in our institution. Circular external fixators (CEF) were used in 35 patients, unilateral limb reconstruction system (LRS) fixators in 24 patients and fixation with plates in 21 patients. Intervention: Surgical procedure included hardware removal in previously operated patients, autogenous grafting in all patients in the plate group and in those patients with atrophic nonunions in the external fixator groups, compression of the nonunion site in all patients. Main Outcome Measurements: Radiological union time, complications, shortening, and disabilities of the arm, shoulder, and hand (DASH) score. Results: Mean follow-up period was 48.1 months (range, 12 to 121). Mean radiological union time was 5.5 months (range, 1.5 to 12) in the CEF group, 5.2 months (range, 3 to 10) in the LRS group, and 5.7 months (range, 3 to 12) in the plate group. Mean DASH score was 23.7 in the CEF group, 18.6 in the LRS group, and 26 in the plate group. There were no statistical differences in terms of union time and the DASH score among the 3 groups. Successful union was achieved in 77 (96.3%) patients. Conclusion: Both external fixation and plate fixation produce excellent results in humeral shaft nonunions if applied properly. The procedure can be tailored to the surgeons experience, keeping in mind that plate fixation demonstrates a longer healing time in those cases that had previous surgeries.

Transfer of latissmus dorsi and teres major tendons without subscapularis release for the treatment of obstetrical brachial plexus palsy sequela

BACKGROUND Patients with obstetrical brachial plexus palsy (OBPP) sequela exhibit adduction and internal rotation contractures. The muscular imbalance may result in secondary bony changes. Tendon transfers and muscular releases may improve shoulder function in these patients. The aim of this study is to evaluate the functional and radiological results of pectoralis major tendon Z-plasty with transfer of latissimus dorsi and teres major tendons to rotator cuff tendons without release of subscapularis muscle in patients with mild sequela of OBPP. MATERIALS AND METHODS Twenty-six consecutive patients, who were treated with tendon transfer and met the eligibility criteria, were included in the study. No additional humeral osteotomy or subscapularis tenotomy was performed. Functional evaluation is made according to range of motion and Mallet scoring system. Preoperative radiologic evaluation was made according to the grading system of Waters. RESULTS A significant increase in shoulder function was found in all patients. Postoperative radiographs revealed glenohumeral congruity was maintained in all patients. Improvement in shoulder abduction and external rotation was higher in patients who were operated before the age of 7. DISCUSSION/CONCLUSION Pectoralis major tendon lengthening with transfer of latissimus dorsi and teres major tendons to rotator cuff is an effective and reproducible technique and can improve shoulder functions in patients with OBPP. Subscapularis release is not always required to overcome internal rotation contracture. Secondary glenohumeral changes might also be prevented with this approach.

Osteochondral autologous graft transfer system in the knee; mid-term results☆

INTRODUCTION The purpose of this study was to determine the effectiveness of the osteochondral autologous graft transfer system in the treatment of chondral and osteochondral lesions of the knee. METHODS Sixty five knees of sixty four patients who underwent autologous osteochondral graft transfer were evaluated with clinical scores and imaging techniques. RESULTS The average follow up was 82.2 (51-145) months. The patients were evaluated according to Tegner activity scale, Lysholm scale and IKDC subjective knee evaluation form. According to all these scales, all patients showed increasing results in various rates in the last follow up. Accordingly, mean increases of 59.2±15.9 points, 3.6±1.4 points, and 42.6±11.5 points were achieved in Lysholm knee scores, Tegner activity scale scores, and IKDC subjective knee evaluation form, respectively (p≤.0001). Moreover, we found no significant correlation between functional results and age, functional results and localization of osteochondral defect, functional results and additional knee pathologies. CONCLUSION In our study we achieved significant increases in all the scales in the last follow up. Furthermore, we found no significant correlation between functional results and age, defect localization and additional knee pathologies.

Evaluation of mobile bearing unicompartmental knee arthroplasty, opening wedge, and dome-type high tibial osteotomies for knee arthritis.

OBJECTIVE Three methods of surgery used in the treatment of knee osteoarthritis (OA) are mobile bearing unicompartmental knee arthroplasty (Oxford UKA), opening wedge high tibial osteotomy (HTO), and dome-type HTO. This article aimed to retrospectively compare these three methods in terms of outcomes for health status, patient satisfaction, and function. METHODS Between 2003 and 2010, 255 knees of 235 patients underwent operations for medial knee OA. Three types of surgery were performed. Group 1 consisted of 109 knees of 94 patients who underwent Oxford UKA. Group 2 was made up of 36 knees of 36 patients who underwent HTO using circular external fixation, and Group 3 comprised 57 knees of 52 patients on whom opening wedge type HTO using locking plate fixation was performed. SF-36 and HSS knee scores were used to compare the functional outcomes among groups. RESULTS Statistically significant differences were found between the preoperative and postoperative measures in all 3 of the treatment groups for physical function, physical role, pain, general health, vitality, social function, emotional role, and mental health according to SF-36 and HSS scores. In the 2nd group, the average correction of the mechanical axis deviation (MAD) was 38 mm with 11.7º along the femorotibial axis and 6.2º along the medial proximal tibial angle (MPTA). In the 3rd group, the average correction in the MAD was 28 mm with 9.7º along the femorotibial axis and 5.6º along the MPTA. All 3 of the treatment alternatives were observed to be sufficient. Satisfactory postoperative results were achieved in the UKA group in terms of social function and mental health, and the patients were able to achieve early rehabilitation and return to their previous life activities. CONCLUSION UKA is the ideal option for patients who wish for the earliest possible return to social and recreational activities.

A rare cause of deep peroneal nerve palsy due to compression of synovial cyst – Case report

INTRODUCTION Synovial cyst is a rare cause of compression neuropathy and its differential diagnosis can be misleading. PRESENTATION OF CASE This article presents clinical, radiological, and histological findings of deep peroneal nerve palsy due to compression of a synovial cyst in a 30-year-old patient admitted with sudden drop foot. DISCUSSION Focal nerve entrapment in lower extremity due to synovial cystis a rare entity. Differential diagnosis is important. Surgical excision is the main treatment method with high success rate. CONCLUSION Synovial cyst compression which can be treated easily with surgical excision should be considered in rapidly progressed drop foot.

Joint Debridement and Metatarsal Remodeling in Freiberg's Infraction

BACKGROUND Freibergs infraction is an osteochondrosis that is characterized by osteonecrosis of the metatarsal head, with pain and tenderness around the metatarsophalangeal joint. We sought to evaluate the outcome of joint debridement and metatarsal remodeling for the treatment of advanced-stage Freibergs infraction. METHODS Between March 1, 2006, and April 30, 2011, 14 patients (eight females and six males) with symptomatic unilateral Freibergs disease refractory to conservative treatment (Smillie stages IV and V) underwent joint debridement with metatarsal head remodeling by two surgeons. To evaluate functional outcome, American Orthopaedic Foot and Ankle Society and 36-Item Short Form Health Survey forms were completed by the patients preoperatively and postoperatively at months 3, 6, and 12. Active-assisted range-of-motion exercise was allowed after 4 weeks of short-leg walking cast wear, and weightbearing on the forefoot was allowed as tolerated. RESULTS Mean patient age was 27.0 years (range, 16-53 years), and mean follow-up was 40.2 months (range, 14-54 months). Mean ± SD American Orthopaedic Foot and Ankle Society and 36-Item Short Form Health Survey scores were 46.8 ± 8.95 and 28.9 ± 4.3 preoperatively and 76.2 ± 9.5 and 45.6 ± 7.7 1 year after surgery, respectively. There was a significant increase in both scores (P ≤ .001). CONCLUSIONS In advanced-stage Freibergs infraction of the second metatarsal, joint debridement and metatarsal head remodeling is a safe and simple therapeutic option, and it provides better quality of life for patients.