Metin Turkmen

Capitellar cartilage injuries concomitant with radial head fractures.

PURPOSE To evaluate the incidence and types of capitellar cartilage injuries associated with higher-grade radial head fractures. METHODS Fifty-one consecutive patients with operatively treated, unstable, displaced Mason type II to III radial head fractures were identified. Ten of 51 patients had capitellar cartilage injuries concomitant with these fractures. All cartilage injuries were identified at the time of surgery except in 1 patient whose injury was determined via computed tomography. There were 8 men and 2 women with an average age of 33 years (range, 24-39 years). Lesions were seen with direct inspection and recorded by location, size, and thickness. RESULTS The incidence of capitellar chondral lesions concomitant with operatively treated Mason type II to III radial head fractures appeared in 10 of 51 patients. The average size was 5 x 5 mm (range, 2 x 2 mm to 10 x 10 mm). Four patients had Mason type II and 6 had Mason type III radial head fractures. The average surface of the cartilage injury was 6 x 7 mm (range, 3 x 6 mm to 10 x 10 mm) for Mason type II fractures and 4 x 4 mm (range, 2 x 2 mm to 5 x 10 mm) for Mason type III fractures. Two Mason type III fractures had full-thickness cartilage lesions, and 4 Mason type III fractures had partial-thickness cartilage lesions. Two Mason type II fractures had full-thickness cartilage lesions and the other 2 had partial-thickness cartilage lesions. CONCLUSIONS Capitellar cartilage lesions frequently occurred concomitantly with higher-grade radial head fractures. The incidence of these lesions increased with greater severity of radial head fractures. Low-grade radial head fractures created higher-grade cartilage lesions as the intact radial head can cause more damage to the capitellum. Careful evaluation of the joint should be performed for these subtle injuries. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.

Comparison of palmar locking plate and K-wire augmented external fixation for intra-articular and comminuted distal radius fractures

OBJECTIVES This study was designed to compare the results of palmar locking plate and K-wire augmented external fixation in the treatment of intra-articular comminuted distal radius fractures. METHODS The study included 30 patients with intra-articular comminuted distal radius fractures. Sixteen patients (11 men, 5 women; mean age 49 ± 16 years) underwent open reduction and palmar locking plate fixation, and 14 patients (11 men, 3 women; mean age 35 ± 10 years) underwent closed reduction and K-wire augmented external fixation. In both groups, eight patients had accompanying injuries. According to the AO/ASIF classification, there were four C1, 10 C2, and two C3 fractures in the locking plate group, and three C1, eight C2, and three C3 fractures in the external fixation group. For functional assessment, joint range of motion and grip strength were measured. The patients were assessed using the Gartland-Werley scale. Subjective functional assessment was made using the QuickDASH scale. On final radiographs, the presence of osteoarthrosis in the radiocarpal joint was assessed according to the Broberg-Morrey criteria. The follow-up period was at least 12 months (26.1 ± 6.1 months in the locking plate group, and 62.7 ± 16.8 months in the external fixation group). RESULTS Wrist flexion (p=0.012) and supination (p=0.003) degrees at final follow-up were significantly greater in the locking plate group. Other range of motion parameters were similar in the two groups. On final radiographic measurements, there were no significant differences between the two groups with respect to losses in palmar angulation, radial length, and radial inclination, and change in ulnar variance. The mean Gartland-Werley scores did not differ significantly (2.4 ± 2.4 with plate fixation, and 2.0 ± 2.8 with external fixation; p>0.05). The results were excellent in 11 patients (68.8%) and good in five patients (31.3%) with plate fixation. The results of external fixation were excellent in 11 patients (78.6%), good in two patients (14.3%), and moderate in one patient (7.1%). The mean QuickDASH scores and time to return to work were similar in patients treated with a locking plate and external fixator (QuickDASH score 2.4 ± 3.0 and 2.9 ± 5.4; 1.9 ± 0.5 months and 2.1 ± 0.7 months, respectively; p>0.05). The mean loss of strength compared to the healthy side at final follow-up was 3% in the locking plate group, and 5% in the external fixation group. Radiographic findings of stage 1 osteoarthrosis were observed in four patients (25%) in the plate group, and in 11 patients (78.6%) in the external fixation group. There were no complications in the locking plate group. In the external fixation group, two patients (14.3%) had regional pain syndrome, three patients (21.4%) had superficial pin and wire tract infections, and one patient complained of adherence at entry sites of the fixator. Overall, nine patients (64.3%) expressed dissatisfaction with the external fixator. CONCLUSION Our results showed no superiority between the two treatment methods with respect to objective and subjective tools of evaluation. Palmar locking plate fixation was associated with full patient satisfaction. K-wire augmented external fixation can be used as a safe method in selected cases in which the severity of distal radius fracture would not allow palmar locking plate fixation.

Effect of mitomycin-C on post-operative adhesions in tendon surgery: an experimental study in rats.

We investigated the effect of mitomycin-C on the reduction of the formation of peritendinous fibrous adhesions after tendon repair. In 20 Wistar albino rats the tendo Achillis was cut and repaired using a modified Kessler technique. The rats were divided into two equal groups. In group 1, an injection of mitomycin-C was placed between the tendon and skin of the right leg. In group 2, an identical volume of sterile normal saline was injected on the left side in a similar fashion. All the rats received mitomycin-C or saline for four weeks starting from the day of operation. The animals were killed after 30 days. The formation of peritendinous fibrous tissue, the inflammatory reaction and tendon healing were evaluated. The tensile strength of the repaired tendons was measured biomechanically. Microscopic evidence of the formation of adhesions and inflammation was less in group 1. There was no significant difference in the tensile load required to rupture the repaired tendons in the two groups. Mitomycin-C may therefore provide a simple and inexpensive means of preventing of post-operative adhesions.

[Open reduction and low-profile plate and/or screw fixation in the treatment of phalangeal fractures].

OBJECTIVES We evaluated the functional results and the effectiveness of open reduction and low-profile plate and/or screw fixation in the treatment of phalangeal fractures. METHODS The study included 17 patients (5 women, 12 men; mean age 33 + or - 10 years; range 17 to 48 years) with closed, nonarticular phalangeal fractures. One patient had two phalangeal fractures. There were 14 proximal and four mid phalangeal fractures, including seven oblique, four spiral, one transverse, and six comminuted fractures. The mean duration from injury to surgery was 2.6 + or - 2.9 days (range 0 to 11 days). Following open reduction, seven fractures were treated with a mini plate and screws, and 11 fractures with mini screws. For functional evaluations, total active motion (TARM) and grip strength were measured and the Q-DASH (Quick-Disabilities of the Arm, Shoulder and Hand) questionnaire was administered. The mean follow-up was 35 + or - 20 months (range 12 to 75 months). RESULTS Union was obtained in all the patients in a mean of 4.5 months. At final assessments, TARM ranged from 160 degrees to 260 degrees (mean 200 + or - 39.5 degrees ), showing excellent, good, and moderate results in six fingers (33.3%), five fingers (27.8%), and seven fingers (38.9%), respectively. An excellent or good TARM was obtained in eight fingers (72.2%) treated with mini screws, and in three fingers (42.9%) treated with plate-screw fixation. The mean grip strength decreased by 7.5% (range 0 to 20%) on the affected side. The mean Q-DASH score was 3.4 + or - 4.4. According to the classification of complications proposed by Page and Stern, seven major (38.9%) and six minor (33.3%) complications were seen. Two patients (11.1%) had delayed union. CONCLUSION Our findings do not justify open reduction and low-profile plate and/or screw fixation as the first choice in the treatment of phalangeal fractures. If plate and screw fixation is necessary, the most minimally invasive method such as screw fixation should be preferred.

Evaluation of Absorbable and Nonabsorbable Sutures for Repair of Achilles Tendon Rupture With a Suture-Guiding Device:

Background: The purpose of this study was to compare the functional and clinical results of Achilles tendon repairs with an Achilles tendon suture-guiding device using nonabsorbable versus absorbable sutures. We hypothesized that the absorbable suture would have clinical results comparable to those of the nonabsorbable suture for Achilles tendon repair with an Achilles tendon suture-guiding system. Methods: From January 2010 to September 2013, 48 consecutive patients who had sustained a spontaneous rupture of the Achilles tendon underwent operative repair with an Achilles tendon suture-guiding device using 2 different suture types. All ruptures were acute. The patients were divided equally into 2 groups according to suture type. In the nonabsorbable suture group, No. 2 braided nonabsorbable polyethylene terephthalate sutures were used, and in the absorbable suture group, braided absorbable polyglactin sutures were used. The average age of the patients was 38 years (range, 28-50 years). Functional outcome scores and complications were evaluated. Results: All patients had an intact Achilles repair after surgery. The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot clinical outcome scores were 98 (range, 90-100) in the nonabsorbable suture group and 96.8 (range, 87-100) in the absorbable suture group. All patients returned to their previous work. The absorbable suture group had fewer postoperative complications (0%) than the nonabsorbable suture group (12.5%) (P < .05). Conclusion: Use of an absorbable suture in the treatment of Achilles tendon repair by an Achilles tendon suture-guiding system was associated with a lower incidence of suture reaction; however, functionally the results were not notably different from those using a traditional nonabsorbable suture. We conclude that repair with absorbable sutures is appropriate for Achilles tendon ruptures. Level of Evidence: Level II, prospective comparative study.

Comparison between fixation with dorsal T plate and palmar locking plate in the treatment of unstable displaced distal radius fractures

OBJECTIVES We compared the results of fixation with dorsal T plate and palmar locking plate in the treatment of unstable displaced distal radius fractures. METHODS Sixty-three patients (64 radii) with distal radius fractures were treated with dorsal T plate (n=41) or palmar locking plate (n=23). The mean age was 46+/-14 years (range 21 to 82 years) in the dorsal and 47+/-14 years (range 18 to 69 years) in the palmar plate groups. The fractures were classified according to the AO/ASIF system. Objective and subjective functional assessments were made using the Gartland-Werley and Quick-DASH scales, respectively. The mean follow-up was 78+/-19 months (range 12 to 101 months) and 18+/-5 months (range 12 to 28 months) with dorsal and palmar plating, respectively. RESULTS The mean Gartland-Werley and Quick-DASH scores were 2.3+/-2.1 (range 0 to 9) and 2.0+/-2.2 (range 0 to 9) with dorsal plating, and 2.0+/-2.1 (range 0 to 6) and 1.9+/-2.7 (range 0 to 9) with palmar plating, respectively. The two groups did not differ with respect to the Gartland-Werley and Quick-DASH scores (p>0.05). Time to return to work or daily activities was also similar (1.9+/-0.3 months vs 1.8+/-0.4 months). However, patients treated with dorsal plating exhibited significantly greater values in the following parameters measured on early and late postoperative radiograms: loss of palmar tilt (p=0.001), radial height (p=0.001), radial inclination (p=0.049), and change in ulnar variance (p=0.049). Moreover, complications were seen in eight patients (19.5%) with dorsal plating, whereas no complications occurred with palmar locking plate (p=0.024). CONCLUSION Although the two fixation methods do not differ with respect to functional results, palmar locking plating seems to provide a more rigid fixation resulting in significantly reduced collapse and a very low complication rate.

Palmaris longus tendon graft versus modified Weaver-Dunn procedure via dynamic button system for acromioclavicular joint reconstruction in chronic cases

BACKGROUND The hypothesis of this clinical study was that coracoclavicular (CC) reconstruction using autogenic palmaris longus graft through the GraftRope (PLG) system (Arthrex, Inc., Naples, FL, USA) would provide superior clinical and radiologic results compared with modified Weaver-Dunn procedure with the dynamic TightRope (Arthrex, Inc.) system (WDT). METHODS Between 2008 and 2013, 32 patients (average age, 39.7 years; range, 22-60 years) underwent surgical reconstruction of chronic acromioclavicular (AC) joint dislocation. A modified WDT procedure was performed in 16 patients and autogenous PLG was performed in the other 16 patients. Patient data were collected retrospectively, with a final follow-up of 44.9 months (range, 29-60 months). The degree of AC joint displacement was evaluated by measuring the CC distance on the anteroposterior and axillary view. Clinical and functional outcomes were compared by American Shoulder and Elbow Surgeons and the Constant scores at final follow-up. RESULTS Comparison between the WDT and PLG groups showed a significantly better outcome in the American Shoulder and Elbow Surgeons and the Constant scores (P < .01), in favor of the PLG group. Both groups showed an increased CC distance compared with the uninjured side, with a mean difference of 1.1 mm for the PLG and 3.3 mm for the WDT groups. A tolerable loss of reduction within the follow-up time was observed. Reduction loss was higher with the WDT group (P < .05). CONCLUSION CC palmaris longus tendon graft reconstruction with GraftRope system was associated with functional and radiologic benefits. The palmaris longus graft with GraftRope system could be used in chronic cases.

Surgical treatment of acute coronoid process fractures

OBJECTIVES This study was designed to assess the results of surgical treatment for type 2-3 coronoid process fractures and to identify factors that might influence the outcome. METHODS Thirteen male patients (mean age 35 years; range 17 to 53 years) were treated with open reduction and internal fixation for displaced coronoid fractures. According to the Regan-Morrey classification, the fractures were type 2 in nine patients (69.2%), and type 3 in four patients (30.8%). Nine patients had associated injuries (elbow dislocation, radial head or olecranon fractures, and/or ligamentous injuries). The mean duration to treatment was 2.3 days (range 1 to 7 days). Functional results were assessed according to the Mayo elbow performance score (MEPS), and signs of arthritis were assessed according to the Broberg-Morrey criteria. The mean follow-up was 41.1 months (range 12 to 96 months). RESULTS A functional range of motion of the elbow joint was achieved in 10 patients (76.9%). The mean elbow range of motion was 110.7 degrees (range 85 degrees to 130 degrees ) and the mean forearm rotation was 134.2 degrees (range 120 degrees to 155 degrees ). Three patients who had comminuted fractures and associated elbow injuries had decreased range of motion. None of the patients exhibited signs of instability. The mean MEPS was 86.5 (range 75 to 100). The results were excellent in four patients (30.8%; the mean MEPS 98.8) having isolated or noncomminuted coronoid fractures, and good in nine patients (69.2%) with comminuted fractures and/or associated bone or ligament injuries. Post-traumatic arthritis was detected in seven patients (53.9%) whose mean MEPS was 81.4. Patients with an excellent functional result did not develop arthritis. All the patients returned to preinjury activity levels. CONCLUSION Coronoid fractures are the most important component of complex elbow injuries. The presence of comminuted fractures, associated bone and ligament injuries, and post-traumatic arthritis affect the outcome adversely.

Warm irrigation fluid does not raise the subacromial temperature to harmful levels while using radiofrequency device.

Sir, Radiofrequency (RF) systems are commonly used for the arthroscopic subacromial decompression. However, there is a concern that the thermal energy generated by the RF probes may have been caused soft tissue damage in the joint if excessive temperatures are reached.[1] Previous studies recommend using room temperature inflowing fluid that differs between 18°C and 24°C.[2] These suggestions bring an important concern, which is hypothermia. Warming of the irrigation fluid may reduce the risk of hypothermia, but the safe limit of the irrigation fluid temperature is unknown.[3] Our hypothesis was that warming the irrigation fluid to actual shoulder temperature would not raise the surrounding temperature to harmful levels while performing bursectomy by RF device.

Surgical treatment results of hand deformities in patients with Apert syndrome

Objectives: Hand deformities in Apert sydrome are complex pathologies and usually consist of complex syndactyly with distal bony fusion in the 2., 3. and 4th fingers, simple syndactyly in the 5th finger, and short thumb, radial clinodactily and synphalangism. Other accompanying deformities and the presence of craniosynosthosis make the treatment plan even more complex. Because it is such a rare disorder, no standard treatment protocol has yet been developed. Methods: In this study, our aim was to evaluate the early results of our standard treatment protocol for Apert’s hands. We evaluated 7 patients with Apert’s hands who were treated bilaterally between the years of 2008 and 2013. We performed a two-stage surgical protocol, the first of which was the bilateral opening of the border fingers and the second stage was the opening of the middle fingers and web space deepening, osteotomy and collateral release of the thumb. Patients were evaluated according to grasping and pinching ability, graft-flap necrosis and cosmetic satisfaction. Results: The mean age at the first operation was 2.7 years and the mean number of operations was 3 per patient. No patient developed graft-flap necrosis and no patients required amputations. All patients were able to perform grasping and pinching functions and families were satisfied with the cosmetic results. Conclusion: Using a two-stage surgical protocol, achieving satisfactory results with a minimal number of operations is possible in patients with Apert Syndrome.