Osman Guven

The use of screw at the fracture level in the treatment of thoracolumbar burst fractures.

Study Design In this prospective randomized study, the results of treating unstable thoracolumbar burst fractures by pedicle instrumentation with and without fracture level screw combination were given. Objective Our aim was to evaluate the efficacy of fracture level screw combination in achieving and maintaining correction in the treatment of unstable thoracolumbar burst fractures. Summary of Background Data Most authors reported that intraoperative correction of sagittal deformity is important for the maintenance of fracture reduction and is one of the most consistent predictor of satisfactory functional outcome. Methods Seventy-two patients with unstable thoracolumbar burst fractures were randomized into 4 groups with equal number of patients. In group 1, patients were treated by segmental posterior instrumentation with 2 levels above and 2 levels below the fracture level fixation, in group 2 they were treated as in group 1 with fracture level screw incorporation. In group 3, patients were treated by short-segment posterior instrumentation with 1 level above and 1 level below, in group 4 they were treated by short-segment posterior instrumentation with fracture level screw incorporation. Clinical and radiologic parameters were evaluated before surgery, after surgery, and at follow-up. Results The average follow-up was 50 months. Fracture level screw combination provided better intraoperative correction and maintenance in the treatment of unstable thoracolumbar burst fractures, which was more prevalent in short-segment fixation group. Conclusions Reinforcement with fracture level screw combination can help to provide better kyphosis correction and offers immediate spinal stability in patients with thoracolumbar burst fracture.

Single-row versus double-row arthroscopic rotator cuff repair in small- to medium-sized tears

HYPOTHESIS Double-row rotator cuff repair leads to superior cuff integrity and clinical results compared with single-row repair. MATERIALS AND METHODS The study enrolled 68 patients with a full-thickness rotator cuff tear who were divided into 2 groups of 34 patients according to repair technique. The patients were followed-up for at least 2 years. The results were evaluated by Constant score. DISCUSSION Despite the biomechanical studies and cadaver studies that proved the superiority of double-row fixation over single-row fixation, our clinical results show no difference in functional outcome between the two methods. It is evident that double-row repair is more technically demanding, expensive, and time-consuming than single-row repair, without providing a significant improvement in clinical results. RESULTS Comparison between groups did not show significant differences. At the final follow-up, the Constant score was 82.2 in the single-row group and 78.8 in the double-row group. Functional outcome was improved in both groups after surgery, but the difference between the 2 groups was not significant. CONCLUSIONS At long-term follow-up, arthroscopic rotator cuff repair with the double-row technique showed no significant difference in clinical outcome compared with single-row repair in small to medium tears.

Incidence of Chondral Lesions of Talar Dome in Ankle Fracture Types

Background: Although the surgical treatment of ankle fractures is well known, a paucity of literature exists correlating chondral lesions with ankle fracture types. Materials and Methods: This study is a retrospective review of patients with absence or presence of chondral lesions that underwent arthroscopically assisted open reduction and internal fixation between June 2002 and April 2005. There were 38 female and 48 male patients (mean age, 41.4 years; mean followup, 33.9 months), and all had an Ankle-Hindfoot Scale score. The relationship between fracture types and presence of lesions was evaluated. Results: Four of 27 fractures with chondral lesions consisted of the bimalleolar type, 6 of 15 fractures with chondral lesions consisted of the trimalleolar type, and 14 of 20 distal fibula fractures had chondral lesions. There was significant greater incidence of chondral lesions associated with distal fibula fractures. The mean AOFAS score was 95.6 among all fractures. Conclusion: There is clear evidence that despite anatomic reduction, postoperative results of ankle fracture repair are not free of complications. We believe inspection of the talar dome should be routinely considered in the surgical repair ankle fractures.

The treatment of distal clavicle fractures with coracoclavicular ligament disruption: a report of 10 cases.

Objective: Fractures of the distal third of the clavicle with coracoclavicular ligament disruption have been associated with delayed union or nonunion. A combined surgical technique for the fracture fixation and ligament repair for acute fractures was developed. The technique includes K-wire fixation and suture anchor placement with Ethibond suture to the coracoid process. The results of this combined technique were evaluated. Design: Prospective, consecutive case series. Setting: Surgical treatment was performed at the Department of Orthopedics and Traumatology. Patients: Ten patients with acute fractures of the distal third of the clavicle were enrolled with a mean follow-up period of 24.1 (range, 12-36) months. Intervention: A single suture anchor was placed on the coracoid process in a vertical position. The Ethibond suture attached to the anchor was used to depress the elevated proximal part of the clavicle by pulling it down to the coracoid process where the anchor was placed. The suture was pulled over the proximal clavicle and tied. The distal fragment was fixed to the proximal clavicle by an intramedullary K-wire. The torn coracoclavicular ligaments were approximated using absorbable suture. Main Outcome Measurements: The patients were evaluated by the Constant scores and Modified Shoulder Rating Scale. Results: The mean Constant score was 96.6 points in the last follow-up. Nine patients had excellent results, and 1 patient had a good result, using the Modified Shoulder Rating Scale. Conclusions: This is a reliable technique with encouraging results for treating displaced distal third clavicle fractures with coracoclavicular ligament disruption.

Arthroscopic repair of radial lateral menicus tear by double horizontal sutures with inside–outside technique

The purpose of this prospective study is to report the outcome of arthroscopic repair of radial lateral meniscus tears at the junction of the anterior horn and body. Five patients with an average age of 27 years were treated. The repair was performed with double horizontal sutures by inside-out technique, using zone-specific, curved cannulae with no enhancement technique. A mean of 2.4 superior and 2.8 inferior stitches were performed. Reduction was obtained in all cases. Patients were evaluated using Lysholm functional knee scores. All patients were clinically and radiologically examined using MRI to assess meniscus integrity at the repair site, over an average follow-up period of 31 months. All patients were able to return to their former level of activity. In all cases, MRI showed a fully healed meniscus at the repair sites, with no further disruption of the debrided area. The mean Lysholm scores improved from 62 preoperatively to 94 postoperatively. The difference between preoperative and postoperative values was found to be statistically significant (p=0.029). No cases of postoperative extra or intra-articular complications were encountered. We found that repairing rather than resecting radial lateral meniscus tears that extend into capsular zone, improves activity level.

Concomitant rotator cuff tear and brachial plexus injury in association with anterior shoulder dislocation: unhappy triad of the shoulder

High incidences of nerve lesions or rotator cuff tears in association with shoulder dislocations have been reported. However, the simultaneous occurrence of these three lesions has only been reported once previously. This case is an example of a not so uncommon injury, which emphasizes the importance of looking for associated brachial plexus and rotator cuff lesions when examining a patient with shoulder dislocation.

Transpedicular decancellation osteotomy in the treatment of posttuberculous kyphosis.

Objective Although the transpedicular decancellation osteotomy is a salvage technique for reconstruction of complex spinal deformities, it is not a procedure used exclusively for patients with kyphosis occurring as a sequel of treated tuberculosis. In this study, 16 adult patients with kyphosis underwent transpedicular decancellation osteotomy between 1993 and 1999. Pain, kyphosis angle, sagittal balance, and functional and neurologic status were the main parameters used for the clinical and radiologic assessment. Methods Sixteen patients with angular kyphotic deformity underwent transpedicular decancellation osteotomy between 1993 and 1999 with at least 5 years of follow-up. There were 6 male and 10 female patients with a mean age of 51.0. The radiologic involvement included the angle of kyphosis and plumb line on the anteroposterior and lateral radiographs. The preoperative and postoperative clinical assessment was performed by the using Oswestry Disability Index. All patients were asked to rate their preoperative and postoperative pain measurement using a pain visual analog scale. Fusion was evaluated on flexion-extension lateral radiographs. Results There were significant corrections in the kyphosis angle and the sagittal balance whereas no radiologic correction loss was observed in any of the patients during follow-ups. When the preoperative and the last follow-up pain visual analog scale and Oswestry Disability Index scores were compared, decrease was documented in both of them. Bony fusion was achieved in all patients and no neurologic complications were detected. Conclusions The transpedicular decancellation osteotomy effectively corrected the sagittal balance and improved pain and functional status. It was a safe and reliable technique in the treatment of posttuberculosis kyphosis.

Tuberculous spondylitis of the lumbosacral region: long-term follow-up of patients treated by chemotherapy, transpedicular drainage, posterior instrumentation, and fusion.

Objective: Tuberculosis spondylitis of the lumbosacral region has rarely been documented in the literature. We present an 87-month follow-up study of 7 of 62 patients with tuberculous spondylitis of the lumbosacral region treated by chemotherapy, transpedicular drainage, posterior instrumentation, and fusion. The purpose was to prove the hypothesis that chemotherapy with transpedicular drainage and single-stage posterior instrumentation-fusion is enough for the prevention of lumbar kyphosis and sagittal offset in selected cases. Methods: There were four men and three women, with average age of 53 years. All patients underwent transpedicular debridement, posterior fusion, and instrumentation. We studied the following data for consideration in these patients: most involved vertebra, vertebral body loss, progress of kyphosis, and sagittal offset. Results: The fourth lumbar vertebra was the most commonly involved vertebral segment. The average preoperative kyphosis was 17.5° and decreased to 5.4° postoperatively. Mean preoperative and postoperative sagittal offset was 0.34 mm and −5 mm, respectively. The average postoperative sagittal offset was increased from −5 to −2 mm at the third month and henceforth remained unchanged. There was no recurrent infection. Conclusion: We consider that transpedicular drainage, posterior instrumentation, and fusion constitute a less demanding operative technique for lumbosacral tuberculous spondylitis for the prevention of lumbar kyphosis and sagittal offset in patients without neurologic deficit and major vertebral body loss. This is the only lumbosacral tuberculous spondylitis series in which the patients were operated on with single-stage posterior surgery and merits a brief report in the light of the larger series.

Effect of Sagittal Plane Deformity of the Lumbar Spine on Epidural Fibrosis Formation After Laminectomy : An Experimental Study in the Rat

Study Design. An animal model of postlaminectomy lumbar column sagittal plane deformity was designed in rats. Objectives. To analyze the effect of lumbar column deformity (lordosis and kyphosis) on postlaminectomy epidural fibrosis formation. Summary of Background Data. Incidence of peridural fibrosis formation after lumbar spinal surgery is considerably high. Instability and sagittal plane deformity of the lumbar spine has been implicated (not proven) as the factors for the development of epidural fibrosis. The effect of traction (kyphosis) or relaxation (lordosis) of the lumbar spine on epidural fibrosis formation is not known. Methods. L4 laminectomies were performed in 30 rats. Three equal groups were formed. In the control group (group I), only laminectomy was performed. In other groups after laminectomy, lumbar lordosis (group II) and kyphosis (group III) was maintained with steel implants. The scar formation was evaluated both histologically and histomorphometrically on the 12th postoperative week. Results Kyphosis developed in group I. The mean amount of peridural scar tissue was significantly more evident in groups I and III than the lordosis group. The extent of adherence to the dura mater and the nerve roots was most apparent in group III. Conclusions. Kyphosis and consequent traction of the lumbar spine is one of the causes for increased epidural fibrosis formation after laminectomy. On the contrary, establishment of lordosis and relaxation of the lumbar spine decreased the scar tissue formation in rats.

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.