Levent Eralp

Prognostic factors in prosthetic replacement for acute proximal humerus fractures.

OBJECTIVES To investigate the effect of some epidemiological and radiologic factors on the outcome of prosthetic replacement in acute proximal humerus fractures. DESIGN Retrospective clinical study. PATIENTS Thirty-two patients [mean age 58 (range 37-83 years)] with a mean follow-up period of 35 months (range 8-80 months). Fifteen cases had Neer type IV, 2 had type III, and 15 patients had fracture-dislocations. MAIN OUTCOME MEASUREMENTS Neers criteria, Constant score, and elevation degree were used. Radiological parameters were union and position of the tuberosities, bone stock, and position of the prosthesis. RESULTS Excellent or good results according to Neers criteria were obtained in 24 of the 32 cases (75%), and unsatisfactory results in 8 cases (25%). Mean Constant score was 68 (range 19-98) and mean elevation degree 113 (range 30-180). Thirty-one cases (97%) had no or mild pain. Cases operated within 14 days following injury had a better general outcome (p = 0.005). The humeral offset was directly correlated to the elevation degree (p = 0.011) and Constant score (p = 0.002), whereas the head height was inversely correlated to the same parameters (p = 0.001 for both). The cutoff point for the humeral offset-general outcome correlation was calculated as 23 mm using ROC curve analysis. The most common complications were problems concerning the tuberosities (50%), and they adversely affected the clinical outcome (p = 0.002). CONCLUSIONS Preoperative delay, problems of tuberosity fixation, and position of the tuberosities were parameters influencing the clinical outcome. Lateralization of the tuberosities results in better scores, whereas their distal transfer can be related to a poorer outcome.

Bifocal Compression-Distraction in the Acute Treatment of Grade III Open Tibia Fractures With Bone and Soft-Tissue Loss: A Report of 24 Cases

Objective To evaluate the results of bifocal compression-distraction method for the acute treatment of open tibia fractures with bone and soft-tissue loss. Design Patients were selected for bifocal compression-distraction (shortening and lengthening) who had open tibia fractures with bone and soft-tissue loss and a Mangled Extremity Severe Score of 6 and below indicating good leg viability. Patients Bifocal compression-distraction osteogenesis using the Ilizarov type circular external fixator was applied to 24 patients with 14 grade IIIA and 10 grade IIIB open tibia fractures with bone and soft-tissue loss. Mean age of the patients was 30.6 years (range 18–53). The mean bone defect was 5 cm (range 3–8.5). The mean soft tissue defect was 2.5 × 3.5 (1 × 2–10 × 5) cm. Interventions Acute shortening at the fracture site was done for patients with bone defects up to 3 cm to achieve apposition of bone ends. Gradual shortening at a rate of 2 mm/d was done for patients who had bone defects more than 3 cm. Leg length discrepancy was overcome by lengthening at the same time through a corticotomy at a proximal or distal level depending on fracture localization, until there was equalization of leg lengths. Results Mean follow-up period was 30 months (range 18–60). Mean bone healing time was 7.5 months (range 4–11). The mean time in external fixation was 7.1 months (range 3–10), and the average external fixator index was 1.4 months/cm. Results were evaluated using the Paley bone and functional assessment scores. The bone assessment results were excellent in 21 and good in 3 patients. Functional assessment scores were excellent in 19, good in 4, and fair in 1 patient. Pin site infections were present in 10.7% of the pin sites. There were 52 complications in 24 patients, for a complication rate per patient of 2.08. Of the complications, 48.1% were problems (minor complications), 38.5% obstacles (major complications requiring a surgical solution), and 13.4% sequelae (true complications). Minor complications included soft tissue inflammation and infection, translation/angulation, and delayed maturation during distraction and transient knee contracture and loss of motion. All grade 1 and 2 soft tissue inflammations and infections healed with nonoperative therapy. Major complications included pin tract infection and reinfection, equinus deformity, frame failure, and premature consolidation, all of which required additional surgery to correct the problem. Sequelae included leg length discrepancy, loss of knee/ankle range of motion, knee flexion contracture, malalignment, and chronic osteomyelitis. Conclusion Bifocal compression-distraction osteogenesis is a safe, reliable, and largely successful method for the acute treatment of open tibia fractures with bone and soft-tissue loss. Further nonoperative or operative treatment can correct most complications.

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.

Complications Encountered During Lengthening Over an Intramedullary Nail

BACKGROUND In limb-lengthening, the quest for increased patient comfort and a reduced period of external fixation has led to techniques such as lengthening over an intramedullary nail. The goals of this study were to investigate the rate and types of complications encountered during lengthening over an intramedullary nail and to identify solutions to these complications. METHODS Forty-two segments (thirty-five femora and seven tibiae) in thirty-five patients were lengthened. The mean age of the patients was 26.6 years, the mean amount lengthened was 6.3 cm (range, 2.5 to 11.5 cm), the mean external fixation index was 18.7 days/cm, and the mean lengthening index was 31.2 days/cm. The patients were followed for a mean period of forty-four months postoperatively. RESULTS Eighteen complications occurred in sixteen (38%) of the forty-two segments for a rate of 0.43 complication per segment. Complications were classified, according to the system of Paley et al., as two problems, thirteen obstacles, and three sequelae. Sixteen of them required additional surgical interventions. A preoperative score of >6.5 on the system of Paley et al., a lengthening of >6 cm, and a lengthening percentage of >21.5% of the original bone length were indicators of a higher probability of the occurrence of complications. CONCLUSIONS Lengthening over an intramedullary nail provides increased patient comfort and reduces the external fixation period. If the problems encountered are treated aggressively, the result of the treatment can be quite satisfactory.

Correction of complex foot deformities using the Ilizarov external fixator.

There are many drawbacks to using conventional approaches to the treatment of complex foot deformities, like the increased risk of neurovascular injury, soft-tissue injury, and the shortening of the foot. An alternative approach that can eliminate these problems is the Ilizarov method. In the current study, a total of 23 deformed feet in 22 patients were treated using the Ilizarov method. The etiologic factors were burn contracture, poliomyelitis, neglected and relapsed clubfoot, trauma, gun shot injury, meningitis, and leg-length discrepancy (LLD). The average age of the patients was 18.2 (5-50) years. The mean duration of fixator application was 5.1 (2-14) months. We performed corrections without an osteotomy in nine feet and with an osteotomy in 14 feet. Additional bony corrective procedures included three tibial and one femoral osteotomies for lengthening and deformity correction, and one tibiotalar arthrodesis in five separate extremities. At the time of fixator removal, a plantigrade foot was achieved in 21 of the 23 feet by pressure mat analysis. Compared to preoperative status, gait was subjectively improved in all patients. Follow-up time from surgery averaged 25 months (13-38). Pin-tract problems were observed in all cases. Other complications were toe contractures in two feet, metatarsophalangeal subluxation from flexor tendon contractures in one foot, incomplete osteotomy in one foot, residual deformity in two feet, and recurrence of deformity in one foot. Our results indicate that the Ilizarov method is an effective alternative means of correcting complex foot deformities, especially in feet that previously have undergone surgery.

An alternative method for the treatment of nonunion of the tibia with bone loss

In this retrospective study we evaluated the method of acute shortening and distraction osteogenesis for the treatment of tibial nonunion with bone loss in 17 patients with a mean age of 36 years (10 to 58). The mean bone loss was 5.6 cm (3 to 10). In infected cases, we performed the treatment in two stages. The mean follow-up time was 43.5 months (24 to 96). The mean time in external fixation was 8.0 months (4 to 13) and the mean external fixator index was 1.4 months/cm (1.1 to 1.8). There was no recurrence of infection. The bone evaluation results were excellent in 16 patients and good in one, while functional results were excellent in 15 and good in two. The complication rate was 1.2 per patient. We conclude that acute shortening and distraction osteogenesis is a safe, reliable and successful method for the treatment of tibial nonunion with bone loss, with a shorter period of treatment and lower rate of complication.

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.

Distal tibial reconstruction with use of a circular external fixator and an intramedullary nail : The combined technique

BACKGROUND Distal tibial reconstruction with use of an external fixator when there is bone loss, limb-length discrepancy, and/or ankle instability is associated with many problems. The technique of limb-lengthening, ankle arthrodesis, and segmental transfer over an intramedullary nail has been introduced to overcome these problems. The present study investigates this combined technique. METHODS Between 2002 and 2005, six patients, who ranged from seventeen to seventy years old, underwent distal tibial reconstruction and ankle arthrodesis with use of a circular external fixator and an intramedullary nail to treat a distal tibial defect following resection for chronic osteomyelitis or tumor or to treat a limb-length discrepancy combined with ankle instability. Functional and radiographic results were evaluated, with use of the criteria described by Paley et al., at an average follow-up of thirty-four months. RESULTS The mean size of the bone defects in three patients was 5.3 cm (2, 7, and 7 cm), and the mean amount of the limb-shortening in four patients was 5.25 cm (range, 4 to 6 cm). The mean external fixation time was 3.5 months, and the mean external fixator index was 0.57 mo/cm. There was no recurrence of infection in the two patients with osteomyelitis. All six patients had excellent bone results, and the functional results were excellent for two patients and good for four patients. There were four complications, three of which were categorized, according to Paley, as a problem (a difficulty that occurs during lengthening and is resolved without operative intervention) and one that was categorized as an obstacle (a difficulty that occurs during lengthening and needs operative treatment). CONCLUSIONS The combined technique is an improvement over the classic external fixation techniques of distal tibial reconstruction with ankle arthrodesis. It reduces the duration of external fixation, thus increasing patient acceptance, and it is associated with a low complication rate facilitating more rapid rehabilitation.

The Ilizarov hip reconstruction osteotomy for hip dislocation: outcome after 4-7 years in 14 young patients.

Treatment of neglected high dislocation of the hip is difficult in adults. We performed hip reconstruction osteotomy, consisting of a proximal abduction and extension osteotomy, and a distal varisation and lengthening osteotomy, utilizing the Ilizarov external fixator in 14 (12 women) patients having a mean age of 20 (12-33) years. The most frequent preoperative complaints were pain, leg-length discrepancy, limping, reduced activity and limited abduction of the hip. After an average follow-up of 68 (55-81) months, the outcome was satisfactory; pain subsided in all patients, the Trendelenburg sign became negative in all but 3 patients, no patient had limb-length discrepancy, and alignment of the extremity was reestablished. However, 3 patients still complained of lurch.

Management of stiff hypertrophic nonunions by distraction osteogenesis: a report of 16 cases.

Objective Hypertrophic nonunions can be managed successfully with distraction. Hypertrophic changes indicate that the tissue at the nonunion site has a biologic healing potential. The missing component is an appropriate mechanical environment to transform a hypertrophic nonunion into solid bone. Design At our institution, the records of 10 male and 6 female patients treated for stiff hypertrophic nonunion with the Ilizarov distraction method were retrospectively analyzed. The average age of the patients was 42.3 years (range 15–69 years). The nonunion time ranged from 8–48 months. All patients had at least 1 cm shortening, 3 patients had a deformity in one plane, and 13 had a deformity in two planes. The pathology was localized to the upper extremity in 5 patients, to the lower extremity in 11 patients, with a periarticular localization in 11 patients. An Ilizarov-type circular external fixator was applied in all patients to correct shortening, to correct deformity, and to achieve a solid union. Results All nonunions healed at an average follow-up of 38.1 months (range 24–95 months). The average time spent in the external fixator was 7.1 months (range 5–10 months). The average preoperative length discrepancy was 2.25 cm (range 1–8 cm), which was eliminated in all patients at the time of frame removal. The average coronal plane angulation of 19.7° (range 15–37°) and sagittal plane angulation of 20.8° (range 5–45°), together with translation in one patient, also were corrected to normal anatomic alignment. Complications included minor pin tract infections and hardware problems; recurrence of deformity was observed in one patient who refused to wear a protective brace after frame removal. Conclusions Hypertrophic nonunions can be managed successfully with distraction. The Ilizarov device can address every aspect of a stiff hypertrophic nonunion, including shortening and deformity.