Mustafa Seyhan

Comparison of reduction methods in intramedullary nailing of subtrochanteric femoral fractures

OBJECTIVE The aim of this study was to compare the outcomes of three reduction methods used during intramedullary nailing of the subtrochanteric femur fractures. METHODS This study included 45 patients with subtrochanteric femur fractures who were treated with intramedullary nailing. Twenty-two patients underwent clamp-assisted reduction, 11 reduction with cable cerclage, and 12 with blocking screws. Reduction techniques were compared with respect to the early postoperative alignment, one year postoperative alignment, time to full weight-bearing, time to union, Harris hip score at one year, operation and fluoroscopy times, blood transfusion amount, complications, and additional interventions. RESULTS The clamp-assisted reduction group had a statistically high mean time to full weight-bearing (p=0.038) and a low mean Harris hip score at one year (p=0.002). The blocking screw groups operation times and fluoroscopy times were statistically long. There was no statistically significant difference between the clamp-assisted reduction and cable cerclage groups in terms of operation times and fluoroscopy times. On the other hand, there were statistically significant differences between the clamp-assisted reduction and blocking screw groups (p=0.0001 and p=0.0001, respectively) and between the cable cerclage and blocking screw groups (p=0.037 p=0.0001, respectively) in terms of operation times and fluoroscopy times. There was no statistically significant difference between the clamp-assisted reduction, cable cerclage and the blocking screw groups in terms of early postoperative alignment, one year postoperative alignment, time to union, complications or additional interventions. CONCLUSION Clamp-assisted reduction leads to a longer time to weight-bearing and a poorer functional status at one year. Operation time and fluoroscopy time were longest in the blocking screw group.

Technique of Kirschner wire reduction and fixation of displaced two-part valgus angulated proximal humerus fractures at the surgical neck.

Summary: This article describes the technique of closed reduction with percutaneous fixation using Kirschner wires in helping the reduction of two-part valgus angulated and displaced proximal humerus fractures at the surgical neck. Traditional open reduction may lead to more accurate anatomic reduction; however, extensive tissue dissection increases the risk of avascular necrosis. Thus, closed reduction of unstable fracture mostly required forceful reduction maneuvers, which can harm the vascular supply and increase hematoma formation. Reduction of the fractured sides can easily be performed by engaging Kirschner -wires with a joystick method and fixation can be secured by using threaded pins. Thirty-six consecutive patients with displaced, two-part, valgus-angulated proximal humerus fractures at the surgical neck were treated by this method. The patients were followed for an average of 38 months. All fractures healed. According to the Constant scoring system, 21 patients (58%) had excellent, 9 patients (25%) had good, and 6 patients (17%) had fair results. The technique of closed reduction with a joystick method and percutaneous fixation is regarded as a reasonable treatment alternative in displaced two-part valgus angulated proximal humerus fracture.

The Effect of Therapeutic Ultrasound on Metallic Implants: A Study in Rats

OBJECTIVE To investigate whether therapeutic ultrasound (US) use over metallic implants has the potential for adverse effects as a result of greater temperature increases at the tissue-metal interface. DESIGN A randomized controlled trial. SETTING A research laboratory. ANIMALS Sprague-Dawley rats (N=40; weight, 230-300g) were used and divided into 3 study groups. INTERVENTIONS In group 1, both limbs of 10 rats were used for evaluation of temperature changes. Metal pins were placed into the femur of the left limb, and the right limbs were used as controls. A thermal sensor was placed into the medulla to record the elevation of tissue temperature during US application. In groups 2 and 3 with 15 rats in each, a midshaft femoral fracture was produced, and intramedullary fixation was performed with metal pins. Group 2 received US treatment for 5 minutes daily and continued for 27 days. Group 3 served as controls. MAIN OUTCOME MEASURES The rats in groups 2 and 3 were killed on postoperative day 30. The specimens were evaluated by radiology, histopathology, and biomechanics. RESULTS The presence of metal in bone did not cause an increased temperature rise. US application did not increase or decrease callus formation, and there was no tissue necrosis. The average removal torques of pins in groups did not show a significant difference. CONCLUSIONS Internal fixation with metallic implants may not be a contraindication for therapeutic US treatment.

A positioning technique for closed intramedullar nailing of tibia fractures.

BACKGROUND We described a method of positioning the patient on the standard operation table that enables manual traction and equipment that is available in almost all operating theaters and compared it with regular positioning technique. METHODS Eighty two patients with unstable unilateral tibia fractures were evaluated and treated in the authors clinic between July 2002 and June 2006. The average age of the patients was 40.6 (29-65) years. The surgical indications included uncomplicated closed fractures, fractures in patients with multiple injuries, and inability to maintain a satisfactory closed reduction. Forty-two fractures that were operated with the new technique and meet these criterias were included in the study. All operations were performed on normal operation tables. RESULTS There was not any case of failure related with the nailing and the presented positioning technique. Intraoperative reduction was achieved with closed method in all patients. In 10 patients, satisfactory reduction was achieved with the help of polar screws in 2 patients and cable system in 8 patients. Anatomic reduction was obtained in the rest of 32 patients. There were no cases of compartment syndrome diagnosed postoperatively in both injured and uninjured side. There were also no neurologic complications and postoperative infection formation related to surgery. CONCLUSION The advantages of this technique is that, it allows precise reduction, control of rotation, and easy imaging access, without increasing operating or screening time and complication.

Fracture-dislocations of the proximal ulna

OBJECTIVE To investigate the relationship between injury patterns, complications, and the functional outcomes of patients with proximal-ulna fracture-dislocations. METHODS Retrospective analysis of 15 patients (10 men, 5 women; mean age, 49.1 years; mean follow-up 49 months) with 6 anterior and 9 posterior fracture-dislocations of the proximal ulna. The proximal ulna was reconstructed with plates and screws in 13 patients and tension-band wiring in 2 patients. At the final follow-up, elbow range of motion (ROM) was measured and Mayo elbow scores (MEPS) were recorded. Broberg-Morrey criteria were used for osteoarthritis staging. RESULTS Concomitant radial-head fracture was seen in all posterior fracture-dislocations. Four ligamentous injuries occurred in this group. All anterior dislocations had trochlear-notch fractures without associated injuries. Mean flexion ROM was 130.6° (100°-140°) and mean loss of extension ROM was 12.6° (0°-30°) in the study group. The mean MEPS score was 92.3 (70-100). Patients with posterior fracture-dislocations showed lower ROM and MEPS and higher level of osteoarthritis than patients with anterior fracture-dislocations. Recurrent dislocations occurred in 2 patients who had ulna fractures fixed with tension-band wiring. CONCLUSION Radial-head fracture and ligamentous injury are specific components of posterior fracture-dislocations. The injury is limited to the trochlear notch in anterior fracture-dislocations. Posterior fracture-dislocations have lower functional outcomes. Proximal-ulna fractures should be fixed with rigid internal fixation (plate and screw) even if the fracture is a simple 2-part fracture.