Sami Sokucu

Locking plate fixation of three- and four-part proximal humeral fractures.

OBJECTIVES We evaluated the functional results of open reduction and internal fixation with a locking plate in patients with three- or four-part fractures of the proximal humerus. METHODS We reviewed 32 consecutive patients (22 women, 10 men; mean age 63 years; range 29 to 82 years) who were treated with open reduction and internal fixation using the PHILOS locking plate for comminuted proximal humeral fractures. According to the Neer classification, 12 patients (mean age 56 years) had three-part fractures, 19 patients (mean age 67 years) had four-part fractures, and one patient had a four-part fracture dislocation. Ten patients were in the age group of <60 years, 22 patients were in the age group of 60=or>years. All the patients were evaluated with plain radiographs preoperatively; in addition, computed tomography was used in 14 patients in whom articular surface and tuberculum displacement could not be assessed adequately. The operation was performed through a standard deltopectoral approach, and minimal soft tissue dissection was used aiming not to impair vascularization of the fracture fragments. A cerclage wire was used to help reduction in 12 patients. An oblique screw was inserted to stabilize the medial colon in cases in which medial cortical contact was insufficient. Bone grafting was not used in any of the patients. Active-assisted and passive exercises of the shoulder were initiated on the second postoperative day. Active abduction to 90 degrees was allowed two weeks after surgery. During follow-up, implant failure, loss of reduction, malunion, and bone healing were assessed on plain radiographs. Bone scintigraphy was performed after 12 postoperative months for the detection of avascular necrosis. The results were assessed using the Constant shoulder score. The mean follow-up period was 25 months (range 18 to 36 months). RESULTS An anatomic or near-anatomic reduction was obtained in 29 patients (90.6%). In two patients, the fractures were fixed in a varus position, and in one patient, the greater tubercle was displaced proximally. All fractures united in a mean of three months (range 2 to 5 months). The mean Constant score of the patients was 79.5 (range 50 to 100). The results were excellent in 13 patients (40.6%), good in nine patients (28.1%), fair in eight patients (25%), and poor in two patients (6.3%). The mean Constant scores were 88.3 (range 69 to 100) and 74.2 (range 50 to 100) in three-part and four-part fractures, and 88.3 (range 71 to 100) and 75.5 (range 50 to 100) in the age groups of <60 years and =or>60 years, respectively. Constant scores showed significant differences with respect to the number of comminution and age groups (p=0.03). Avascular necrosis was observed in two patients. None of the patients had reduction loss, implant failure, deep infection, or neurovascular injury, and none required implant removal. CONCLUSION Preservation of humeral head vascularity through minimal soft tissue dissection, fixation with a locking plate, and early postoperative motion were effective in decreasing potential complications following surgical treatment of three- and four-part proximal humeral fractures. The degree of fracture comminution and age of the patients affect functional results significantly.

Open minimally invasive Achilles tendon repair with early rehabilitation: functional results of 25 consecutive patients.

BACKGROUND Various treatment techniques have been described for the treatment of acute Achilles tendon rupture. However, there is no consensus among orthopaedic surgeons regarding the surgical technique and the postoperative rehabilitation program. Mid-term functional outcome results of the patients who had undergone open minimally invasive repair of fresh Achilles tendon ruptures followed by an early rehabilitation programme were evaluated. METHODS Twenty-five consecutive patients who underwent open minimally invasive repair of Achiles tendon ruptures during January 2004-October 2005 were independently reviewed at an average follow-up of 34 months (range 24-45 months). The mean age of the patients was 41 (35-47). A functional rehabilitation protocol based on early range of motion exercises was used after surgery. The American Orthopaedic Foot and Ankle Society score was used to evaluate the outcomes of the patients. Ankle range of motion; thigh, calf and ankle circumferences of the injured leg and the contralateral side, return to work and sports activities time were evaluated. RESULTS One patient had a partial rerupture and one had superficial wound infection. The mean American Orthopaedic Foot and Ankle Society score was 93 (80-100). Patients returned to work at 3 weeks (range 1-5 weeks) and to preinjury sportive activities at 3 months (range 2-4 months). Ankle ROM and circumference measurements did not reveal a significant difference between the two sides. CONCLUSION These results suggest that open minimally invasive Achilles tendon repair and an early rehabilitation programme provides satisfactory results with early return to previous functional status with low complication rates.

Anatomic Course of the Superficial Branch of the Radial Nerve in the Wrist and Its Location in Relation to Wrist Arthroscopy Portals: A Cadaveric Study

PURPOSE The aim of this study was to assess the course of the superficial branch of the radial nerve (SBRN) at the level of the wrist and its branches in relation to wrist arthroscopy portals. METHODS Dissections were performed on 11 hands from 6 cadavers in the section starting from the point where the SBRN begins to emerge and ending at the terminal branches of the dorsal hand. The distribution of the SBRN, the distance from the superficial branch to the dorsal portals used in wrist arthroscopy, and the distance from the superficial branch to the anatomic determinants (styloid process of the radius, Lister tubercle) were studied. RESULTS At the level of the wrist, the nerve bifurcated into 2 branches in 8 of 11 wrists (73%) and into 3 branches in 3 of 11 wrists (27%). The mean distance from the SBRN where it was first detected proximal to the Lister tubercle was 73 mm. The mean distance between the styloids was 52 mm; the distance between the Lister tubercle and styloid process of the radius was 23 mm. At the wrist level, the distance from the branch closest to the radial side to the Lister tubercle was 28 mm (L-D1), 21 mm (L-D2/3), and 7 mm (RS-D1). The distance of the closest nerve branch to the 3-4 portal was 9 mm. The distances of the other portals were 5 mm (1-2RMC-D1), 8 mm (1-2RMC-D2/3), 8 mm (1-2P-D1), and 9 mm (1-2P-D2/3). CONCLUSIONS The limited size of the area where portals can be positioned and the anatomic variations between individuals are major obstacles in developing a guideline for reducing the risk of SBRN injury in wrist arthroscopy. CLINICAL RELEVANCE Great care must be taken when using the 1-2 portal. We suggest making a skin-only incision for this portal and then using blunt dissection to help prevent injury to the SBRN.

Minimally invasive treatment of distal tibial fractures with locking and non-locking plates.

Background: The purpose of this study was to evaluate the clinical performances of stainless steel nonlocking plates and titanium locking plates in minimally invasive medial plating of extra-articular metaphyseal fractures of the distal tibia. Materials and Methods: Between 2004 and 2006, 43 patients who sustained closed fractures of the distal tibia metaphysis were managed with either a stainless steel nonlocking plate (Group 1, n = 21) or a titanium locking plate (Group 2, n = 22). Clinical and radiographic data were retrospectively reviewed. Function was assessed with use of the American Orthopaedic Foot and Ankle Society ankle-hindfoot instrument. The average followup period was 25 months. Results: The average AOFAS foot and ankle scores in Group 1 and Group 2 at final followup were 85 and 81, respectively. Fracture reduction was anatomical or nearly anatomical without angular displacement in all cases except one patient in Group 2. (p > 0.05) The average time to full, unprotected weightbearing in Group 1 and Group 2 were 15 weeks and 18 weeks, respectively (p < 0.05). Conclusion: Minimally invasive medial plating with titanium locking plates resulted in prolonged secondary healing both in comminuted and simple fracture patterns compared to conventional stainless steel nonlocking plates. We believe that in biological fixation of distal tibial fractures, similarly good results may be obtained with both materials as the locking technology had a greater effect on stability. Level of Evidence: III, Retrospective Comparative Study

Volar locking plate fixation of unstable distal radius fractures

OBJECTIVES We evaluated radiographic and functional results of volar locking plate fixation of unstable distal radius fractures. METHODS The study included 27 patients (15 males, 12 females; mean age 45 years; range 18 to 77 years) who were treated with volar locking plate fixation for unstable distal radius fractures. Twenty-two patients (81.5%) had AO type C and five (18.5%) had type B fractures. Two patients (7.4%) had type I open fractures. Dorsal and volar angulation were present in 21 (77.8%) and six (22.2%) fractures, respectively. Four patients (14.8%) also had elbow dislocation and/or fracture and nine patients (33.3%) had disruption of the distal radioulnar joint. Autologous iliac crest graft was used in 10 patients (37%). Postoperative assessments included range of movement and grip strength measurements, and radiographic parameters using the Stewart criteria. Functional results were assessed using the Q-DASH (Quick-Disabilities of the Arm, Shoulder and Hand) questionnaire and the Gartland-Werley scale. The mean follow-up was 18 months (range 12 to 34 months). RESULTS All fractures united without a problem within a mean of 6.5 weeks (range 6 to 8 weeks). The following parameters became equal to the unaffected side: ulnar variance (n=21, 77.8%), radial inclination angle (n=13, 48.2%), radial tilt angle (n=8, 29.6%), and radial height (n=11, 40.7%). The mean radiographic Stewart score was 0.5 (range 0 to 3). The mean grip strength of the operated side was 72.4% (18 kg) of the normal side. The mean Q-DASH and Gartland-Werley scores were 8.3 (range 0 to 70.5) and 4.7 (range 0 to 16), respectively. According to the Gartland-Werley scale, the results were excellent in 12 patients (44.4%), good in 12 patients, and moderate in three patients (11.1%). Three complications (11.1%) occurred, including loss of alignment in two patients, and screw-related discomfort in one patient. CONCLUSION Volar locking plate fixation is an effective treatment in the anatomical and functional restoration of unstable distal radius fractures.

Clinical results of intramedullary nailing following closed or mini open reduction in pediatric unstable diaphyseal forearm fractures

OBJECTIVES We compared the clinical results of open reduction with a mini incision and closed reduction in pediatric unstable diaphyseal forearm fractures treated with intramedullary nailing. METHODS We retrospectively evaluated 45 children who were treated with intramedullary nailing for unstable middle third diaphyseal forearm fractures. Before intramedullary nailing, 24 patients (group 1; 5 girls, 19 boys; mean age 10 years; range 5 to 14 years) underwent open reduction with a mini incision, and 21 patients (group 2; 5 girls, 16 boys; mean age 11.5 years; range 8 to 13 years) underwent closed reduction. There were 16 closed, seven Gustilo-Anderson type 1, and one type 2 open fractures in group 1, and 15 closed and six type 1 open fractures in group 2. The mean time to surgery was 5 days (range 1 to 20 days) in group 1, and 3.1 days (range 1 to 5 days) in group 2. Rush rods or Kirschner wires were used for fixation. In group 1, both radius and ulna were fixed in all the patients, whereas fixation involved both bones in 18 patients, and only ulna in three patients in group 2. Functional results were evaluated according to the criteria of Price et al. The mean follow-up period was 33 months (range 12 to 89 months) in group 1, and 37 months (range 14 to 52 months) in group 2. RESULTS Union was obtained in a mean of 7.1+/-1.0 weeks (range 6 to 9 weeks) in group 1, and 6.5+/-1.0 weeks (range 6 to 10 weeks) in group 2. The implants were removed after a mean of 7.2+/-1.7 weeks (range 6 to 10 weeks) in group 1, and 8.1+/-0.4 weeks (range 8 to 10 weeks) in group 2. The two groups differed significantly with respect to union and implant removal times (p=0.036 and p=0.002, respectively). According to the criteria of Price et al., the results were excellent in 19 patients (79.2%) and 18 patients (85.7%), and good in five patients (20.8%) and three patients (14.3%) in group 1 and 2, respectively. There was no significant difference between the functional results of the two groups (p>0.05). Complications showed a similar profile in the two groups, being one major (4.2%) and seven minor (29.2%) in group 1, one major (4.8%) and eight minor (38.1%) in group 2. None of the patients had complications such as limb-length discrepancy, epiphyseal damage, angular or rotational deformity, synostosis, or limited elbow or forearm range of motion. CONCLUSION Closed reduction or open reduction with a mini incision before intramedullary nailing yield similar functional results, with a similar complication profile in the treatment of pediatric unstable diaphyseal forearm fractures.

Extramembranous transfer of the tibialis posterior tendon for the correction of drop foot deformity

OBJECTIVES We evaluated the effectiveness of extramembranous transfer of the tibialis posterior (TP) tendon for the treatment of drop foot deformity. METHODS The study included 13 patients (6 females, 7 males; mean age 30 years; range 10 to 46 years) who underwent 15 tendon transfers for drop foot deformity. Ten patients (76.9%) had deformity due to unrepairable nerve injuries, which were associated with surgical procedures in six patients and trauma in the remaining four. In four feet (26.7%), the TP tendon was turned from the intero-anterior aspect of the tibia and fixed by tenodesis to the lateral cuneiform bone, while in 11 feet (73.4%), it was transferred to the extensor hallucis longus, extensor digitorum communis, and peroneus tertius tendons. The patients were assessed according to the Stanmore system questionnaire. The mean follow-up was 25.3 months (range 12 to 80 months). RESULTS According to the Stanmore system, the results were poor in two feet (13.3%), moderate in three feet (20%), good in three feet, and very good in seven feet (46.7%). All the patients were satisfied with the final outcome. The mean foot dorsiflexion was 5 degrees (range, -5 degrees to 10 degrees ), which was 10 degrees in four feet (26.7%), and 5 degrees to 10 degrees in six feet (40%). Apart from complaints of bulging in four patients (30.8%) in the dorsum of the foot due to tendon and suture material, no complications were seen during the early postoperative period. CONCLUSION Extramembranous transfer of the TP tendon for the treatment of drop foot deformity enables the patients to walk without the aid of orthosis and increases their quality of life.

Early results of open mosaicplasty in osteochondral lesions of the talus

OBJECTIVES The aim of this study was to evaluate early results of open mosaicplasty for the treatment of talus osteochondral lesions associated with chronic complaints. METHODS The study included eight patients (1 male, 7 females; mean age 35 years; range 18 to 74 years) with osteochondral lesions of the talar dome. The mean duration of symptoms was 11 months and the mean lesion size was 17 x 9 mm. The lesions were of medial localization in five patients, and lateral localization in three patients. According to the Bristol classification, the stages of the lesions were as follows: stage IIa (n=2), IIb (n=1), III (n=2), IV (n=1), and V (n=2). Mosaicplasty was performed via a mini arthrotomy with osteotomy. Functional assessments were made using the AOFAS (American Orthopaedic Foot & Ankle Society) scoring system pre- and postoperatively. Pain was assessed using a visual analog scale. Regeneration of new cartilage tissue at the lesion site was monitored by magnetic resonance imaging. The mean follow-up was 17 months (range 8 to 34 months). RESULTS The osteotomy site healed in a mean of six weeks in all the patients. The mean pre- and postoperative AOFAS scores were 58 (range 40-68) and 89 (range 80-97), respectively (p<0.005). Pain scores decreased from a mean of 8 (range 5 to 10) to 2 (range 1 to 4; p<0.005). Surgery-related complication was seen in one patient. All the patients returned to preoperative levels of activity and occupation. Magnetic resonance imaging showed graft incorporation in all the patients. CONCLUSION Open mosaicplasty is a simple, safe, and effective alternative in the treatment of cartilage losses of the talar dome, in particular those of cystic type and exceeding 10 mm in size.

Comparison of intramedullary nail and plate fixation in distal tibia diaphyseal fractures close to the mortise

BACKGROUND In this study, we aimed to compare the functional and radiological results of intramedullary nailing and plate fixation techniques in the surgical treatment of distal tibia diaphyseal fractures close to the ankle joint. METHODS Between 2005 and 2011, 55 patients (32 males, 23 females; mean age 42 years; range 15 to 72 years) who were treated with intramedullary nailing (21 patients) or plate fixation (34 patients) due to distal tibia diaphyseal fracture were included in the study. The average follow-up period was 27.6 months (range, 12-82 months). The patients were evaluated with regard to nonunion, malunion, infection, and implant irritation. The AOFAS (American Orthopaedic Foot and Ankle Society) scale was used for the clinical evaluation. RESULTS No statistically significant difference was found between the two surgical methods with respect to unification time, AOFAS score, accompanying fibula fracture, material irritation, and malunion. Nine patients had open fractures, and these patients were treated with plate fixation (p=0.100). Nonunion developed in three patients who were treated with plates. Infection occurred in one patient. Anterior knee pain was significantly higher in patients who were treated with intramedullary nails. There was no malunion in any patient. CONCLUSION As the distal fragment is not long enough, plate fixation technique is usually preferred in the treatment of distal tibia diaphyseal fractures. In this study, we observed that if the surgical guidelines are followed carefully, intramedullary nailing is an appropriate technique in this kind of fracture. The malunion rates are not significantly increased, and it also has the advantages of being a minimally invasive surgery with fewer wound problems.

Comparative evaluation of radiographic and functional outcomes in the surgical treatment of scaphoid non-unions

OBJECTIVE The aim of our study was to evaluate the correlation between the radiological signs of union and functional outcomes in patients with surgically treated scaphoid non-unions. METHODS In our study, we evaluated 13 patients who underwent surgery at our clinic for complaints resulting from an unhealed scaphoid fracture. Of the scaphoid non-unions, 9 were on the scaphoid body and 4 were on the proximal pole. According to Slades classification system, there were two Grade 4, eight Grade 5, and three Grade 6 fractures. The patients were all male with a mean age of 31, with 25 months of mean time between the onset of trauma and surgery. All fractures were treated through open reduction with autogenous bone grafting (cancellous in 4 cases; corticocancellous in 9 cases) and fixation with compression screws. Bone morphology and carpal alignment were assessed through radiography, using the scaphoid index and scapholunate angle measurements, respectively. Range of motion and grip strength measurements together with the modified Mayo wrist scores were used in the assessment of wrist functionality. RESULTS Average duration of follow-up was 16 months. In 10 patients, radiological union was attained in a mean time of 12.4 weeks following the operation. There was a substantial improvement in grip strength and range of motion values after surgery. The preoperative mean modified Mayo wrist score of 41.5 improved to 79.2 postoperatively. Accordingly, 4 patients had perfect, 2 had good, 5 had fair and 2 had poor results. The surgical treatment allowed the preoperative mean scapholunate angle of 45.8° and the preoperative mean scaphoid index of 0.69 to be reduced to 32° and 0.6, respectively. The humpback deformity present in 11 patients before the surgery was restored in 10 patients by reconstruction of the scaphoid bone length. Abnormal carpal alignment was restored in 4 of these patients. No statistically significant correlation was found between the functional results and the surgically attained structural restorations and union process. CONCLUSION The surgical treatment of scaphoid fracture non-unions can correct bone morphology and resolve alignment problems but might not be sufficient for the improvement of functional results.