Onder Kilicoglu

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.

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.

Primary fixation strength of rotator cuff repair techniques: a comparative study

PURPOSE The goal of the study was to compare the primary fixation strength of transosseous suture, suture anchor, and hybrid repair techniques for rotator cuff repair. TYPE OF STUDY Animal model experiment. METHODS Thirty-two sheep shoulders were divided into 4 homogeneous groups, according to bone density and tendon dimensions. Infraspinatus tendons were transected from their insertions and reattached using 4 different techniques. Group 1 was repaired with a single Mason-Allen stitch and 2 transosseous tunnels for each end of the suture, knotted on the lateral cortex of proximal humerus; group 2 was repaired with double Mason-Allen stitches and 2 transosseous tunnels; group 3 was repaired with 2 Corkscrews (Arthrex, Germany); and group 4 was repaired with 2 Corkscrews combined with a single Mason-Allen transosseous suture. All specimens were tested for their fixation strengths with a material testing system. RESULTS The mode of failure in group 1 was mainly suture breakage. In groups 3 and 4, the tendons pulled out from the sutures. In group 2, sutures broke the bony bridge between the 2 tunnels. The mean load to failure value was 160.31 +/- 34.59 N in group 1, 199.36 +/- 11.73 N in group 2, 108.32 +/- 15.98 N in group 3, and 214.24 +/- 28.52 N in group 4. Anchor fixation was significantly weaker compared with other groups (P <.001). Combination of a transosseous suture and anchor fixation (group 4) was significantly stronger than the single transosseous suture (group 1) and double anchor techniques (group 3) (P <.001). CONCLUSIONS Hybrid technique was the strongest among the tested rotator cuff repair techniques. With the addition of one transosseous suture to two anchors, the strength of the repair could be doubled.

Time-Dependent Changes in Failure Loads of 3 Biceps Tenodesis Techniques In Vivo Study in a Sheep Model

Background Failure load of the tendon–fixation material–bone unit has a crucial importance for the rehabilitation protocol after tenodesis procedures. Purpose To investigate and compare the time-dependent changes in fixation strengths of 3 proximal biceps tenodesis techniques. Study Design Controlled laboratory study. Methods Two intraosseous techniques (suture sling and tenodesis screw) and 1 extraosseous technique (2 suture anchors) were investigated. Biceps tenodesis was performed on 45 shoulders of 26 sheep, 15 shoulders for each technique. Twelve similar cadaveric sheep shoulders (4 for each technique) provided the day 0 results. Sheep were sacrificed at 3, 6, and 9 weeks, and specimens were tested for the failure load of the tenodeses. Results All 3 tenodesis techniques were found to have similar failure loads at all time intervals tested. All 3 curves remained below the failure load of the intact tendon (862 ± 96 N) and above their day 0 results for the study period; similarly, at each time interval, results tended to be better compared to the previous test. The tenodesis screw group exhibited significantly higher failure loads at week 3 (419 ± 53 N) compared to day 0 values (164 ± 45 N) (P=. 009). The same level of significance was observed at week 6 in the remaining 2 groups. Conclusion Tenodesis of the biceps tendon on the proximal humerus at an extra-articular site does not weaken after surgery. The tenodesis screw group had a significantly higher increase in the fixation strength within the first 3 weeks. Clinical Relevance No significant differences could be found between the failure loads of all 3 investigated tenodeses for the first 9 weeks.

S1 pediculoiliac screw fixation in instabilities of the sacroiliac complex: biomechanical study and report of two cases.

Objective A new technique for posterior sacroiliac fixation is described and compared with conventional techniques. Patients/Material and Methods A patient with sacral alar fracture (zone 1) and another one with sacroiliac joint instability due to tuberculous infection underwent fixation using screws placed in the S1 pedicle and the iliac bone. Vertical stability of the new technique also was investigated using polyurethane pelvic bone analogs and compared with anterior double plating (group P) and iliosacral screw fixation (group ISS) techniques. Results Healing was obtained and reduction was maintained in both patients on the final follow-up examination at 2 years postoperatively. Vertical loading tests revealed that failure loads within the first 10 mm of displacement of the new pediculoiliac screw fixation technique (group PIS) was higher than plating (P = 0.03) and lower than ISS techniques (P = 0.002). Ultimate failure load of the PIS technique was slightly higher than plating (P = 0.277) and lower than ISS techniques (P = 0.003). With the addition of an iliosacral screw to the pediculoiliac screw construction (PIS+ISS), the PIS technique became more stable in early (P = 0.110) and ultimate failure loads (P = 0.003). Conclusions Pediculoiliac screw fixation for sacroiliac joint disruptions and zone I sacrum fractures using iliac and S1 pedicle screws is a new and effective alternative for obtaining and maintaining anatomic reduction.

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.

Monitoring the genotoxic effects of radiosynovectomy with Re-186 in paediatric age group undergoing therapy for haemophilic synovitis

Summary.  Purpose: The aim of this study was to investigate the genotoxic effect on the peripheral blood lymphocytes potentially induced by Re‐186 in paediatric age group undergoing radiosynovectomy for haemophilic synovitis, by using chromosomal aberration analysis (CA) and the micronuclei (MN) assay for detecting chromosomal aberrations, as well as the sister chromatid exchanges (SCE) technique for assessing DNA damage. Methods: Cytogenetic analyses were evaluated in 20 boys (mean age: 13.8 ± 2.7 years) before, and 2 and 90 days after radiosynovectomy from the peripheral lymphocytes of the patients. Joint retention and extra‐articular spread of the radionuclides were evaluated by using quantitative gamma camera imaging. Results: Imaging after radiosynovectomy revealed local lymph node visualization in 8 (40%) patients and hepatosplenic visualization in 3 (15%) patients due to extra‐articular leakage of radioactive material. The mean frequency of chromosome aberrations (0.2 ± 0.4/1000 cells) determined prior to the onset of therapy was not significantly increased in comparison with control values obtained 2 days (0.4 ± 0.5/1000 cells) and 90 days (0.2 ± 0.4/1000 cells) after therapy (P = 0.754 and P = 1.0). In the analysis of MN and SCE, when we compare the baseline levels, the mean MN and SCE frequencies were slightly higher in the control analyses performed 2 and 90 days after radiosynovectomy but there were no significant differences between baseline and control levels (χ2 = 2.621, P = 0.270 and F = 0.573, P = 0.569, respectively). Conclusion: The major finding of this study with relatively small sample is that, radiosynovectomy with Re‐186 does not seem to induce early genotoxic effects on the peripheral blood lymphocytes in paediatric age group.

Functional results of the parallel-plate technique for complex distal humerus fractures

OBJECTIVES We evaluated functional results of patients treated with open reduction and internal fixation with the parallel-plate technique for complex distal humerus fractures. METHODS Twenty-one patients (14 males, 7 females; mean age 47 years; range 16 to 85) underwent open reduction with olecranon osteotomy and internal fixation with the parallel-plate technique for distal humerus fractures accompanied by highly intra-articular or metaphyseal comminution (n=10), intra-articular comminution and osteoporosis (n=7), and intra-articular and metaphyseal comminution with bone loss (n=4). According to the AO classification, there were 12 C3, six C2, and three C1 type fractures. Eight patients had open fractures. The mean time to surgery was six days (range 1 to 17 days). Functional results were evaluated using the Mayo elbow performance score, Jupiter elbow score, and DASH (Disabilities of the Arm, Shoulder and Hand) score. The mean follow-up was 28 months (range 12 to 48 months). RESULTS The mean total range of motion was 90.2+/-31.1 degrees, flexion was 118.1+/-17.4 degrees, and extension was 27.8+/-17.4 degrees. The mean Mayo elbow performance score and DASH score were 86.1+/-12.6 and 7.6+/-9.5, respectively. According to the Jupiter elbow scores, the results were excellent in seven patients, good in 11 patients, moderate in two patients, and poor in one patient. Radiographically, solid union was achieved in all the patients. Heterotopic ossification of varying degrees was seen in seven patients, two of whom underwent resection of heterotopic ossification due to severe limitation of movement. Debridement was performed in one patient due to the development of deep infection. Chondrolysis of the elbow occurred in one patient. Patients with open fractures had significantly lower range of motion than those with closed fractures (p<0.05), but the Mayo elbow performance score and DASH score did not differ significantly in this respect (p>0.05). CONCLUSION Functional results are satisfactory in distal humerus fractures treated with stable osteosynthesis and parallel-plate technique that allow early active motion.

Survival analysis of Y‐90 radiosynovectomy in the treatment of haemophilic synovitis of the knee: a 10‐year retrospective review

Despite recent advances including new therapeutic options and availability of primary prophylaxis in haemophiliacs, haemophilic synovitis is still the major clinical problem in significant patient population worldwide. We retrospectively reviewed our 10‐year experience with Y‐90 radiosynovectomy to determine the outcome in the knee joints of patients with haemophilic synovitis. Between 2002 and 2012, 82 knee joints of 67 patients with haemophilic synovitis were treated with Y‐90 radiosynovectomy. The mean age was 16.8 ± 7.8 years (range: 5–39 years). The mean follow‐up period was 39.6 ± 25.6 months (range: 12–95 months). Failure of therapy represented re‐bleeding after a radiosynovectomy was used as an end point in patient time to progression (TTP) analysis. The median TTP was calculated as 72.0 ± 3.6 months (95% CI 64.8–79.1 months) in Kaplan–Meier analysis. The 1, 3 and 5‐year survival rates were 89%, 73% and 63% respectively. Longer TTP (hazard ratio for progression, 2.5; P = 0.00) was evident in patients who have greater reduction in bleeding frequency within 6 months after radiosynovectomy. We did not find a relationship between the TTP and the following variables: age, type and severity of haemophilia, the presence or absence of inhibitor, the radiological score, range of motion status of joints and the pretreatment bleeding frequency. We concluded that Y‐90 radiosynovectomy in knee joint represents an important resource for the treatment of haemophilic synovitis, markedly reducing joint bleeding and long‐term durability, irrespective of the radiographic stage and inhibitor status.

Time-dependent reduction in load to failure of wedge-type polyglyconate suture anchors.

SUMMARY Thirty-two absorbable (polyglyconate) and 24 nonabsorbable (polyacetal) wedge-type suture anchors (TAG; Acufex, Mansfield, MA) were implanted into sheep tibiae. Load to failure tests were performed on the day of insertion and at weeks 3, 6, and 12, followed by macroscopic examination. Failure type was suture breakage for nonabsorbable anchors in all groups, with average forces of 142.5 +/- 4.8 N on the first day, 138.0 +/- 6.6 N in week 6, and 135.6 +/- 2.9 N in week 12. In the absorbable group, suture breakage occurred on the first day with a mean force of 133.5 +/- 4. 2 N. In weeks 3, 6, and 12, suture cutout occurred with average forces of 33.75 +/- 5.0 N, 23.25 +/- 2.2 N, and 23.25 +/- 5.9 N, respectively. For absorbable anchors, results at weeks 3, 6, and 12 were significantly lower compared with initial results (P <.001). These results show that wedge-type polyglyconate anchors lose 75% of their initial pullout strength within the first 3 weeks and 84% in 6 weeks.