Mehmet Cakmak

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.

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.

Ilizarov fixator for treatment of Legg-Calvé-Perthes disease.

Eleven hips of 11 patients (8 boys, 3 girls; mean age, 7.5 years) with a diagnosis of Perthes disease underwent distraction using an Ilizarov external fixator. All patients had one or more Catterall signs of poor prognosis, with four hips classified as Herring class B and seven as class C. Patients were followed for a mean of 36 months. Average time for wearing the fixator was 99 days (range, 40-150 days). After fixator removal, containment was lost in two more patients and was sustained in only four patients. The most common complication was pin track infection, which occurred in eight patients. The low rate of success found does not justify the routine use of this technique.

Total hip arthroplasty in patients with ankylosing spondylitis: Midterm radiologic and functional results

Introduction The aim of this study was to evaluate the clinical and radiological outcomes of total hip arthroplasty (THA) in patients with Ankylosing Spondylitis (AS). Patients and methods One hundred five hips of 61 AS patients (mean age: 41.3 ± 10.2 years) who underwent THA between 1997 and 2012 were included into the study. Dorrs classification of proximal femoral geometry, acetabular protrusio, bone ankylosis, acetabular protrusion, Brooker classification of heterotopic ossification (HO), Gruen and Charnley classifications of implant loosening were used in radiographic assessments. Patients were called back to return for an additional long-term follow-up for functional assessment. Results Cementless total hip arthroplasty was used in 83 hips (79%) and cemented TKA was used in 22 hips (21%). The overall rate of aseptic loosening was 7.6% at a mean follow-up of 5.4 years. Femoral loosening was statistically similar in cemented and cementless femoral components (14% vs. 8%, p = 0.089). Acetabular component loosening was statistically higher in patients with any degree of HO (p = 0.04). Regardless of the type of femoral implant (cemented or cementless), femoral component loosening was higher in Dorrs type C patients (p = 0.005). The average pre-operative HSS was 46.6 ± 16.3, and it improved to 80.7 ± 18.7 at last follow-up (p < 0.01). Conclusion Revision incidence was similar in between ankylosed and non-ankylosed hips. While complication rates are high, significant functional improvement can be achieved after THA in patients with AS.

Hinge Types and Positioning

The difference and advantage of the Ilizarov external fixator (IEF) is the ability to be modified during the operation until the device is removed. The motion of the fragments has some technical terms (e.g., compression, distraction, rotation, translation, angulation).

Sagittal Plane Deformities and Malorientation Test

The knee joint moves in the sagittal plane. For that reason, the knee, hip, and ankle alignment on the sagittal plane varies in walking phases. Although we use the static deformity analysis on the frontal plane, dynamic factors have to be considered for determining sagittal plane deformities. In this chapter sagittal plane deformities and malorientation test will be explained.

Oblique Plane Deformities

The frontal (coronal) and sagittal planes are the standard reference planes. Radiographs that correspond with these planes are AP and lateral X-rays, respectively. If there is an angulation on both frontal and sagittal planes, it means the deformity is on the oblique plane. Deformities other than those on the frontal and sagittal planes are oblique plane deformities. These deformities were previously known as biplanar deformities. However, this description was wrong because they were uniplanar angular deformities in the oblique plane.

K-Wire and Schanz Screw Application Techniques

Ilizarov’s circular external fixator consists of modular and configurable parts. Mechanical stability between bone and fixator comes from K-wires made of flexible and elastic steel. These wires limit the osteonecrosis and cause minimal damage in bone and marrow. In this chapter, application of the K-wires and Schanz screws will be explained. It is the essential skill for the application of the Ilizarov’s method.

Frontal Plane Deformities and Drawing Axes of the Long Bones

Every long bone has two axes, the anatomic axis and the mechanical axis. In order to have a better understanding before analyzing the deformities, these axes and the relations between them and some terms of use must be understood.

Diaphyseal Deformities of the Tibia

Because of the close relationship with the knee joint, proximal deformities of the tibia will be explained in the chapter on knee deformities. Likewise, distal deformities of the tibia will be explained in the chapter of ankle deformities because of their close relationship. Diaphyseal deformities of the tibia (or bowing deformities) will be explained in this chapter.