Koray Unay

Comparative analysis of pedicle screw versus hybrid instrumentation in adolescent idiopathic scoliosis surgery

The expectations of both the patient and surgeon have been greatly revised in the last 10xa0years with the introduction of pedicle screws (PS) in spinal surgery. In this study, we have retrospectively evaluated and compared the results of PS instrumentation and the Hybrid System (HS), the latter consists of pedicle screws, sublaminar wire and hooks. The mean follow-up period was 60.1xa0months (range: 49–94xa0months) for the patients of the HS group and 29.3xa0months (range: 24–35xa0months) for those of the PS group. In the HS group, pedicle screws were used at the thoracolumbar junction and lumbar vertebra, the bilateral pediculotransverse claw hook configuration was used at the cranial end of the instrumentation, sublaminar wire was used on the concave side of the apical region and the compressive hook was used on the convex side. In the PS group, PS were used on the concave sides at all levels and on the convex side of the cranial and caudal end of instrumentation, in the transition zone and at the apex. The two groups were comparable for variables such as mean age, preoperative Cobb angle, thoracic kyphosis angle, lordosis angle, coronal balance, flexibility of the curve, apical vertebra rotation (AVR), apical vertebra rotation (AVT) and the number of vertebrae included in the fusion (pu2009>u20090.05). The parameters of values of correction, ratio of correction loss, AV derotation, AVT correction ratio, amount of blood loss, operation time, postoperative global coronal and sagittal balance, thoracic kyphosis angle and lumbar lordosis angle were measured at the last follow-up and used for comparing the HS and PS groups. There was no statistically significant difference between the groups for correction ratio, postoperative coronal balance, postoperative thoracic kyphosis and lumbar lordosis angle, operation time, amount of blood loss and number of fixation points (pu2009>u20090.05) The difference for the ratio of correction loss, AV derotation angle and the AVT correction ratio at the last follow-up visit and for the total follow-up period between the groups was found to be statistically significant (pu2009<u20090.05). Although it is possible to obtain a similar amount of correction by either instrumentation system, the loss of correction seems to be lower with the more rigid PS construction. The PS system also has a stronger effect on vertebral bodies, thereby providing better AV de-rotation. There was no significant difference (pu2009>u20090.05) between the groups in terms of correction rate, postoperative coronal and sagittal balance, operation time, blood loss and number of fixation points. This may indicate that anchor points are more important than the use – or not – of screws. Correction durability and AV de-rotation was better with PS instrumentation, while AVT was better corrected by HS instrumentation (pu2009<u20090.05). We propose that the reason for the better correction of AVT with HS instrumentation is the forceful translation offered by the sublaminar wire at the apical region, while the reason for the better correction durability of the PS instrumentation may be due to the fact that multiple pedicle screws which afford three-column control are better at maintaining the correction and preventing late deterioration.RésuméDans la chirurgie rachidienne les attentes des patients et des chirurgiens se sont grandement modifiées depuis 10 ans, depuis l’introduction des vis pédiculaires (PS). Nous avons pour cette étude évalué de façon rétrospective et comparé les résultats de vis pédiculaires avec une instrumentation hybride (HS) utilisant à la fois des vis pédiculaires, des fils et des crochets sous laminaires. Matériel et méthode : le suivi moyen a été de 60.1 mois (49 – 94 mois) pour le groupe HS et de 29.3 mois (24 – 35 mois) pour le groupe PS. Dans le groupe HS, les vis pédiculaires ont été utilisées à la jonction dorsolombaire, thoracolombaire et au niveau lombaire avec un dispositif pédiculo transverse terminant le montage à la partie supérieure, les fils laminaires étant utilisés dans la partie concave et, dans la partie convexe avec un crochet en compression à la partie la plus apicale de la courbe. Dans le groupe vis pédiculaires, celles-ci ont été utilisées dans la partie concave à tous les niveaux et dans la partie convexe et caudale pour stabiliser l’instrumentation. Les groupes ont été très comparables en termes d’âges, d’angles de Cobb pré-opératoires, de cyphose thoracique, de lordose lombaire, de rotation et de souplesse de la courbe et de nombre de vertèbres inclus dans le montage (Pu2009>u20090.05). Les valeurs de correction, de pertes de correction, de dérotation, de pertes sanguines, de temps opératoires, de cyphose thoracique et de lordose lombaire ont été mesurées à la dernière revue des patients en comparant les deux groupes HS et PS. Résultats : il n’y a pas de différences significatives entre ces deux groupes en ce qui concerne la correction post opératoire, la cyphose thoracique post opératoire, la lordose lombaire post opératoire, le temps opératoire, les pertes sanguines et le nombre de points de fixation du matériel (pu2009>u20090.05). Par contre, il existe une différence en ce qui concerne les pertes de correction et l’angle de rotation, il est possible d’obtenir une correction similaire avec chaque instrumentation. Les pertes de correction sont beaucoup moins importantes avec le système vis pédicullaires, plus rigides (PS) qui entraînent une meilleure rotation. En conclusion : pour le taux de correction post opératoire, le temps opératoire, les pertes sanguines, le nombre de points de fixation les deux groupes ne montrent pas de différences significatives (pu2009>u20090.05). Ceci nous indique que les points de fixation du matériel sont plus importants que l’utilisation de vis. La stabilité à long terme et la dérotation sont nettement améliorées avec l’instrumentation PS, l’AVT étant mieux corrigé avec l’instrumentation HS (pu2009<u20090.05). Nous pensons que pour avoir une meilleure correction de l’AVT comme réalisé avec l’instrumentation HS, il est nécessaire d’avoir une translation entraînée par les fils sous laminaires dans la région apicale. Par contre les raisons d’une meilleure correction et d’une meilleure stabilité dans le groupe PS sont secondaires aux multiples vis pédiculaires qui contrôlent beaucoup mieux les trois colonnes au niveau du montage avec une bonne stabilité empêchant une perte de correction secondaire.

Treatment of reverse oblique trochanteric femoral fractures with proximal femoral nail

Treatment of reverse oblique trochanteric femoral fractures is still challenging. We present the results of our proximal nailing surgery performed for reverse obliquity intertrochanteric fractures using two lag screws and evaluated the quality of the reduction, operative time, complications and functional status of the patients. Fifteen patients with AO/OTA 31 A-A3 fractures were treated by proximal femoral nailing in our trauma centre. The mean Harris hip score was 74.66 (range 65–96) and the mean Barthel activity score was 15.71 (range 12–20). The mean duration of surgery was 48 minutes and the average consolidation time was 8.6xa0weeks. No intraoperative complications or postoperative technical failures and no stress shielding as evidenced by the lack of cortical hypertrophy at the level of the tip of the implant were detected. Intramedullary nailing with proximal femoral nails may be a good option in the treatment of reverse obliquity intertrochanteric fractures.

Distal unlocked proximal femoral intramedullary nailing for intertrochanteric femur fractures

We investigated whether a proximal femoral nail (PFN) having two lag screws can be implanted without distal locking screws in AO/OTA 31-A1 and 31-A2 intertrochanteric femur fractures. Twenty-four patients with AO/OTA 31-A1 and 31-A2 fractures were treated with a PFN without distal interlocking by a single surgeon. The mean follow-up was 12xa0months (range: 7–23). Clinical and functional outcome was assessed according to the Harris hip score and Barthel’s activity score. The fractures healed in all patients; the average consolidation time was 14xa0weeks (range: 9–28). Fourteen patients had excellent and good results, nine patients had fair results, and one patient had a poor result according to the Harris hip score; 17 patients had a high range of mobility according to the Barthel activity score. Our results suggested that the PFN can be successfully implanted without distal interlocking in 31-A1 and 31-A2 fractures.RésuméL’objectif est d’analyser les résultats de l’enclouage fémoral sans verrouillage distal pour des fractures inter trochantériennes de type AO/OTA31-A1 et 31-A2. Matériel et méthodes : 24 patients présentant ce type de fracture ont été traités par un enclouage fémoral proximal sans verrouillage par le même chirurgien. Le suivi moyen a été de 12 mois (7 à 23). Les résultats cliniques et fonctionnels ont été analysés selon le score de Harris et selon le score d’activité de Barthel. Résultats : toutes les fractures ont consolidé chez tous les patients. Le temps de consolidation moyen a été de 14 semaines (de 9 à 28 semaines). 14 patients ont eu un excellent résultat, 9 patients un résultat moyen et un un résultat médiocre selon le score de Harris. 17 patients avaient une bonne mobilité de la hanche selon le score de Barthel. En conclusion : nos résultats permettent de penser que la fracture inter trochantérienne du fémur proximal peut être traitée de façon positive avec un clou fémoral sans verrouillage distal pour des fractures de type 31-A1 et 31-A2.

Glove perforation in hip and knee arthroplasty

BackgroundThe transmission of blood-borne pathogens during surgery is a major concern. Surgical gloves are the primary barrier between the surgeon and the patient. Surgical procedures that need manual handling of bony surfaces or sharp instruments have the highest risk of glove perforations. The frequencies and the sites of surgical glove perforations in arthroplasty procedures were assessed.MethodsWe assessed the surgical glove perforations in total hip and knee arthroplasty procedures. Double standard latex gloves were used. A total of 983 outer and 511 inner gloves were tested. The gloves of all the surgical team members were tested for perforations during the first and second hours of surgery.ResultsThere were 18.4% outer and 8.4% inner glove perforations. The most frequent site of perforation was the second digit of the nondominant hand (25.5%). We found that hip and knee arthroplasty had significantly more glove perforation risk for the surgeon in the first half of the operation rather than the second half, and 57.8% of the perforations were at the index finger and the thumb.ConclusionsArthroplasty procedures still have high glove perforation rates despite the use of double gloving with frequent changes. Extra augmentation of the gloves in selected areas of the hand, in addition to double gloving, may be safer and more cost-effective than double gloving alone.

Examination tests predictive of bone injury in patients with clinically suspected occult scaphoid fracture

BACKGROUNDnThis study aims to identify the physical examination tests most indicative of bone injury in patients with clinically suspected occult scaphoid fractures.nnnMETHODSnTen physical examination manoeuvres were performed on 41 patients with a history of a fall on an outstretched hand and tenderness at the anatomical snuffbox and scaphoid tubercle without a radiographically visible fracture line. The results of wrist examination and subsequent magnetic resonance imaging (MRI) were recorded. The sensitivity, specificity, positive and negative predictive values, accuracy and likelihood ratio of the physical examinations were calculated for the patients who had bone injury confirmed by MRI.nnnRESULTSnThe distribution of MRI-confirmed conditions was as follows: 13 cases-no bone involvement; 12 cases-scaphoid fractures; 9 cases-fissures at the distal end of the radius; 6 cases-bone-bruise and 1 case-triquetral fracture. The symptoms most indicative of bone injuries were pain during pinching by the thumb and index fingers and pain during pronation of the forearm.nnnCONCLUSIONnThe two above-mentioned manoeuvres were most indicative of bone injury in patients with clinically suspected occult scaphoid fracture. These examinations may reduce the number of unnecessary MRI examinations.

The Influence of Atorvastatin on Tendon Healing: An Experimental Study on Rabbits

Hyperlipidemia is a major risk factor for coronary heart disease. The most commonly used antihyperlipidemic drugs are 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitors (statins), of which atorvastatin is one of the most widely used. Little is known about the relationship between tendinopathy and HMG CoA reductase inhibitors (statins) or the effects of atorvastatin use on tendon healing following surgical repair of tendon rupture. We hypothesized that atorvastatin negatively affects this healing process. The Achilles tendons of 16 New Zealand rabbits were ruptured surgically and repaired with sutures. Eight of the rabbits were given oral atorvastatin. The other 8 served as a surgical control group. Six weeks postoperatively, all the rabbits were sacrificed, and the repaired tendons were removed. After standard histological preparation, fibroblastic activity, re-vascularization, collagenization, collagen construction, and inflammatory-cell infiltration were evaluated. On comparing the atorvastatin and surgical control groups, we observed no difference in fibroblastic activity. Although it did not reach statistical significance in our study, a difference was noted in revascularization, collagenization, and inflammatory cell infiltration; and a statistical difference was observed in collagen construction. Doubt remains about the adverse effect of atorvastatin use during tendon healing. Further investigations in animal and human models are needed on the effects of tendon healing when atorvastatin is administered for a longer time frame prior to the injury.

No evidence of infection after retrograde nailing of supracondylar femur fracture in gunshot wounds.

BACKGROUNDnThe aim of the study was to determine whether osteomyelitis of the femur or septic arthritis of the knee develops after retrograde intramedullary nailing of the femur performed within 7 days of supracondylar femur fracture, secondary to gunshot wounds, without skin defects.nnnMETHODSnFifteen patients with a mean age of 27.8 years (range, 18-52 years), with supracondylar fractures of the femur due to gunshot wounds and without skin defects. Retrograde intramedullary nails were inserted through the intercondylar notch of the femur. We evaluated whether osteomyelitis of the femur or ipsilateral septic arthritis of the knee joint developed postoperatively.nnnRESULTSnNone of the patients who were followed up for a mean period of 11.7 months (range, 9-16 months) showed evidence of ipsilateral septic arthritis of the knee or osteomyelitis of the femur.nnnCONCLUSIONnRetrograde intramedullary nailing of the femur can be performed in patients with supracondylar fractures of the femur due to gunshot wounds, and without skin defects, in the first 7 days after the trauma. Neither osteomyelitis of the femur nor septic arthritis of the knee develops in these patients.

Minimally invasive reduction technique in split depression type tibial pilon fractures.

Tibial pilon fractures usually result from high energy trauma and present as a challenge to the orthopedic surgeon. Accurate reduction of the joint with meticulous care for the surrounding soft tissues is mandatory. We present a case report in which an anterior cruciate ligament targeting device is used with a minimally invasive technique under arthroscopic and fluoroscopic guidance for Orthopaedic Trauma Association 43-B2.3 type pilon fracture treatment.

Intramedullary nailing versus percutaneous locked plating of distal extra-articular tibial fractures: a retrospective study

The aim of this study is to compare distal tibial fractures (4–10xa0cm proximal to the plafond) treated by intramedullary nailing with those treated by percutaneous locked plating and to assess the clinical and radiographic results, complication rates, and the need for secondary procedures. Thirty-six patients received percutaneous locked plate treatment and 25 patients received intramedullary nail treatment. The results obtained from these two treatment methods were assessed by comparing infection rates, starting time for wight-bearing, local implant irritation, union and malunion rates and along with secondary procedures. In the percutaneous locked plate group, two deep infections, four superficial infections, two nonunions, one malunion and 10 local implant irritations were observed. In the intramedullary nail group, one nonunion, four malunions and two local implant irritations were observed. The incidence of deep and superficial infections, local implant irritations and secondary procedures in the percutaneous locked plate group was greater than those in the intramedullary nail group. The time to full weight bearing was shorter in the intramedullary nail group. There was no significant statistical difference in malunion and nonunion rates between the two groups. The need for secondary procedures was more common in group receiving the percutaneous locked plate treatment and the time to full weight bearing was shorter in the intramedullary nail group.

A new radiographic measurement method for evaluation of tibial torsion: a pilot study in adults.

Computed tomography (CT) frequently is used to determine torsional abnormalities. However, its use in clinical practice may be limited. We present a new method for measuring tibial torsion using conventional radiographs. We compared the method with several clinical methods and with CT measurement in 44 lower extremities of 25 subjects. The radiographic method agreed well with all of the clinical methods, and this agreement was better than agreement between CT and clinical examination. The best agreement was between thigh-foot angle and the radiographic method. The proposed radiographic measurement is a practical method for evaluation of tibial torsion in outpatient clinics without the need for specialized equipment.Level of Evidence: Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.