Murat Altay

The use of polymethylmethacrylate in the management of hydatid disease of bone

Hydatid disease of bone is rare. It probably represents between 0.5% and 4% of all human hydatid disease and, in about 60% of patients, affects the spine or pelvis. Between 1986 and 1998, we treated 15 cases of bone hydatidosis. Curettage, swabbing with povidone iodine and filling the defect with polymethylmethacrylate (PMMA) were carried out in ten patients. Three of these had a recurrence after five years, but seven had no signs of relapse during a mean follow-up of 52 months. We believe that the combination of antihelminthic therapy, wide resection and the use of PMMA gives the best outcome in the treatment of bone hydatidosis.

Open reduction via posterior triceps sparing approach in comparison with closed treatment of posteromedial displaced Gartland type III supracondylar humerus fractures.

The results of closed and open reduction via posterior approach with percutaneous pinning of posteromedial displaced supracondylar humerus fractures in children were evaluated. Fifty-five consecutive patients with Gartland type III fractures were reviewed. The mean follow-up period was 22 months (12–48 months). The closed reduction group consisted of 32 patients and the open reduction group with the posterior approach using the triceps-sparing method consisted of 23 patients. Both groups were stabilized with cross Kirschner wire fixation and followed the same protocol. In comparison with closed reduction, despite the fact that better bone alignment was obtained with open reduction, longer union time (7 vs. 5.8 weeks), significantly reduced range of motion of the elbow (12.3° vs. 3.8°), poorer functional outcomes and bad cosmetics because of hypertrophic scar tissue of the skin were found. The patients were analyzed according to their Bauman angle and Flynn criteria: good or excellent functional and cosmetic results were 91% in the closed reduction group but 52% in the open reduction group. On the basis of results of this study, closed reduction and percutaneous fixation of the posteromedial totally displaced fractures are preferable to open reduction with posterior approach.

Comparison Between External Fixation and Cast Treatment in the Management of Distal Radius Fractures in Patients Aged 65 Years and Older

PURPOSE The aim of this study was to compare the functional and radiographic outcomes of dorsally displaced distal radius fractures treated by closed reduction plaster cast fixation (CRPCF) and external fixation (EF) in patients 65 years and older. METHODS This retrospective and nonrandomized study comprised 46 consecutive patients older than 65 years who had distal radial fractures. Patients were divided into 2 groups according to treatment: a CRPCF group and an EF group. All the fractures were dorsally displaced and AO/ASIF type A or C, without articular stepoff or gap. Cases were evaluated based on the criteria of Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score, wrist range of motion, and radiologic results. RESULTS The mean follow-up period was 25.1 months. Union was achieved in all cases. Although it was not a statistically significant difference, posttreatment complications were more common in the CRPCF group (10 patients) than in the EF group (7 patients). In the CRPCF group, most complications were discomfort from the cast, whereas in the EF group, most were pin site infections. The average wrist extension and ulnar deviation (clinically) and palmar tilt and radial height (radiologically) were statistically better in the EF group at the final follow-up. The mean DASH scores were 20.3 in the CRPCF group and 21.9 in the EF group. There was no statistically significant difference in the DASH scores; in wrist flexion, radial deviation, pronation, supination, grip strength, or pinch strength (clinically); or in ulnar variance or radial inclination (radiologically). There was no correlation between the DASH scores and palmar tilt and ulnar variance. CONCLUSIONS We concluded that both CRPCF and EF are useful methods for distal radius fractures in elderly patients. The results showed significant differences in wrist extension and ulnar deviation.

Squamous Cell Carcinoma Arising in Chronic Osteomyelitis in Foot and Ankle

Background: Squamous cell carcinoma arising from chronic osteomyelitis is uncommon, and although most occur in the lower extremities, occurrence in the foot and ankle is rare. Methods: Between February, 1991, and May, 2003, we treated 14 patients (13 men and one woman) with squamous cell carcinomas arising in chronic osteomyelitis. The foot and ankle were affected in seven patients, and these comprised our study group. All seven patients were male, with a mean age of 59.5 (range 54 to 63) years. An average of 27 (range 4 to 50) years passed between draining of the osteomyelitis and the diagnosis of the malignancy. Average followup was 68 (22 to 147) months. Results: Six patients had amputations and one had limb salvage. Regional lymph node clearance was done in four patients, but metastasis occurred in only one patient who later died of the disease. Conclusion: In treating recalcitrant ulcers that have not responded to conventional modes of therapy, malignancy should be ruled out and a biopsy done. The treatment of choice for squamous cell carcinoma is amputation. Routine regional lymphadenectomy at the time of amputation seems unnecessary, but regional lymphadenopathy persisting for 3 months after amputation warrants surgical intervention.

Nondrainage Decreases Blood Transfusion Need and Infection Rate in Bilateral Total Knee Arthroplasty

This retrospective study enrolled 526 patients undergoing bilateral total knee arthroplasties at our institution. In nondrainage group (Group 1) of 255 patients (510 knees), a disposable elastic sterile exsanguination tourniquet (HemaClear), wound closure in layers and Jones Bandage, without pre-tourniquet removal hemostasis or Hemovac drain were used. In drainage group (Group 2) of 227 patients (454 knees), pneumatic tourniquet, post-deflation hemostasis, a Hemovac drain and Jones bandage were used. The maximal drop in hemoglobin was significantly greater in Group 2 than Group 1 (P < 0.001). Also infection rate was significantly lower in Group 1 (P = 0.017). The use of sterile tourniquet removed after wound closure without Hemovac drain decreases blood transfusion need, infection rate, tourniquet related pain and postoperative complications.

ALENDRONATE ENHANCES ANTIBIOTIC-IMPREGNATED BONE GRAFTS IN THE TREATMENT OF OSTEOMYELITIS

Bisphosphonates are systemic drugs. There is limited knowledge about their effects when applied locally and in osteomyelitis treatment. A prospective longitudinal randomised controlled study was designed in rat tibia to test the efficacy of local or systemically administered bisphosphonates for controlling the osteolytic reactions and possible effects on local infection control. Tibial osteomyelitis was induced in 72 Wistar albino rats with Staphylococcus aureus ATCC 25923 strain. Débridement was performed on all rats in all groups. No other treatment was given to the control group. Treatment groups received “plain bone grafts”, “vancomycin-loaded bone grafts”, “vancomycin-loaded bone grafts+systemic alendronate”, “alendronate-impregnated bone grafts” and “vancomycin+alendronate-impregnated grafts”. Study results were evaluated by swab cultures, radiology, quantitative computed tomography, dual-energy X-ray absorptiometry (DEXA) and histopathology. S. aureus was eradicated in groups II and IV by the sixth week. Diaphyseal widening, bone deformation, diaphyseal widening and osteolysis scores were significantly lower (p < 0.05), and bone mineral content, density measurements and DEXA scores were significantly higher (p = 0.001) with alendronate administration. Histology revealed marked osteoblastic activity. Local alendronate interfered with local infection control. Even though local alendronate at the given dose has stronger effects, the possible effects on the local inflammatory process needs to be clarified.RésuméLes Bisphosphonates sont des médicaments utilisés par voie systémique avec un effet systémique. Nous n’avons aucune connaissance sur leurs effets lorsqu’ils sont utilisés localement, notamment dans le traitement de l’ostéomyélite. Une étude prospective longitudinale randomisée a été réalisée sur le tibia de rat afin de tester l’efficacité de l’administration systémique ou locale des bisphosphonates sur les réactions ostéolytiques et sur de possibles effets sur une infection locale. L’ostéomyélite tibiale a été induite chez 72 rats albinos Wistar avec une inoculation d’un staphylocoque Aureus ATCC 25923. Une mise à plat a été réalisée chez tous les rats, dans tous les groupes. Il n’y a pas eu d’autres traitements dans le groupe contrôle. Les autres groupes ont reçu une greffe osseuse, soit une greffe osseuse imprégnée de vancomycine soit une greffe osseuse imprégnée de vancomycine et avec injection systémique d’alendronate, soit une greffe osseuse imprégnée d’alendronate et enfin une greffe osseuse imprégnée d’alendronate et de vancomycine. Les résultats ont été évalués par cultures bactériologiques, radio, QCT, DEXA et histopathologie. Le staphylocoque doré a été éradiqué dans les groupes II et IV après six semaines. Le gonflement diaphysaire, la déformation osseuse et l’élargissement diaphysaire avec lésions ostéolytiques ont été de façon significative diminués (p < 0.05), de même que la densité minérale osseuse et le score DEXA ont été significativement plus élevés (p = 0.001) ceci grâce à l’administration de l’alendronate. L’examen histologique a mis en évidence une activité ostéoblastique et l’on peut affirmer que l’administration locale d’alendronate a une influence sur une infection locale. Cependant, l’alendronate administré localement peut avoir des effets importants au niveau du processus inflammatoire qu’il faudra étudier secondairement.

Range of Motion of the First Metatarsophalangeal Joint after Chevron Procedure Reinforced by a Modified Capsuloperiosteal Flap

Background: This study analyzed the range of motion of the first metatarsophalangeal joint following the chevron procedure with increased stabilization using a modified capsuloperiosteal flap in the treatment of hallux valgus cases. Materials and Methods: Forty-three feet of 40 patients were treated with modified chevron osteotomies. The patient selection criteria included failure of conservative treatment, painful deformity, age between 18 and 50, hallux valgus and intermetatarsal angles less than 40 degrees and 17 degrees, respectively, and no osteoarthritic changes of the metatarsophalangeal joint. The passive range of motion of the first metatarsophalangeal joint was compared to the hallux valgus and intermetatarsal angles. Results: The mean age of patients was 30.9 ± 9.0 (range, 18 to 46) years. The preoperative mean hallux valgus angle was 32.2 (range, 22 to 40 degrees), whereas postoperatively it was 13.1 (range, 3 to 22 degrees). The preoperative mean passive total range of motion, dorsiflexion and plantar flexion were found to be 80.2 (range, 71 to 99 degrees), 66.8 (51 to 86) degrees and 13.4 (range, 7 to 23 degrees), respectively, whereas postoperatively these values were 69.2 (range, 48 to 85 degrees), 58.6 (range, 43 to 75) degrees and 10.8 (range, 1 to 20 degrees). According to Bonney and MacNab subjective scores, the feet were evaluated as follows: 12 as excellent, 26 as good, and 5 as moderate. According to objective scores, the evaluation was as follows: 27 as excellent, 14 as good, 1 as moderate, and 1 as poor. Conclusion: We believe that the chevron procedure reinforced by modified capsuloperiosteal flap causes minimal irritation and damage to adjacent soft tissues. Furthermore, we conclude that this method is a benefical means of managing moderate hallux vagus deformities by decreasing the stiffness after surgery.

Results of medial open reduction of developmental dysplasia of the hip with regard to walking age.

This study aimed to evaluate the outcome of medial open reduction for developmental dysplasia of the hip (DDH) in patients before and after walking age. A minimum 5-year radiographic and clinical follow-up compared 29 patients (group 1) before walking age with 38 patients (group 2) after walking age for DDH. The correction ratio of acetabular index was similar in both groups postoperatively (41.8% for group 1 and 44.9% for group 2), and it was statistically not significant (P>0.05). The Kalamchi–MacEwen classification showed no correlation between operative age and the rate of avascular necrosis (P>0.05). This report presents similar complication rates as that of the Severin criteria for medial open reduction of the hip and challenges the conventional belief that a medial open reduction for the treatment of DDH in a walking-age child at short-term to mid-term follow-up has comparable results.

A DIFFERENT PERSPECTIVE FOR RADIOLOGICAL EVALUATION OF EXPERIMENTAL OSTEOMYELITIS

IntroductionRadiological scoring systems used in experimental osteomyelitis combine several factors into a single score. Because response of bone tissue to infection is a dynamic process, such systems have limited ability to differentiate between treatment groups. The analyzing of radiological criteria separately at different stages of the disease may be superior to a general score.Methods and methodsOsteomyelitis was induced with Staphylococcus aureus in the left tibiae of 72 adult Wistar albino rats. The rats were assigned to one of six different treatment groups. Their radiographs were graded (1) by the use of previously published general scoring systems and (2) by the evaluation of periosteal reaction, bone deformation, diaphyseal widening, osteolysis, soft tissue swelling, bone mineral content (BMC) and bone mineral density (BMD), separately. The assessments were performed 3 weeks after induction as well as 3 weeks and 6 weeks after treatment.ResultsPeriosteal reaction and diaphyseal widening demonstrated significant differences within 3 weeks of treatment, contrary to the general scores. After 6 weeks of treatment, individual criteria, including diaphyseal widening, osteolysis and BMC but only one of the general grading scores, were able to differentiate between treatment groups.ConclusionsFor differentiation of treatments in experimental osteomyelitis individual assessment of radiological criteria is superior to previously published general scoring systems.

Minimally Invasive Plate Osteosynthesis of Distal Tibia and Fibular Fractures Through a Single Distal Anterolateral Incision

Treating distal tibia fractures is often challenging given the extent of soft tissue damage around the fracture and the risk of infection and other complications with internal fixation and the accompanying incisions. Minimally invasive plate osteosynthesis minimizes these complications and can be performed through a single incision. From April 2009 to January 2011, we treated 20 patients who had both tibial and fibular distal fractures through a distal anterolateral approach with this technique. The mean follow-up period was 15.5 (range 12 to 26) months. The mean interval to bony union was 21 (range 18 to 25) weeks. A 5° varus deformity was found in 1 patient. Another patient, who had a history of alcohol consumption and smoking, developed wound necrosis that was treated successfully with debridement and without skin grafting. The mean American Orthopaedic Foot and Ankle Society score for all patients was 91.8 (range 84 to 97). The anterolateral, minimally invasive plate osteosynthesis technique is a useful method for treating distal tibial and fibular fractures at the same level, with a low complication rate.