Senol Akman

Results of open reduction and plate osteosynthesis in comminuted fracture of the olecranon

HYPOTHESIS Using radiologic and clinical results, we studied the outcome of patients who underwent open reduction and plate osteosynthesis for comminuted olecranon fractures. MATERIALS AND METHODS We retrospectively studied 18 patients (5 women [27.8%] and 13 men [72.2%]; mean age, 41 years [range, 19-67 years]) with comminuted fractures of the olecranon who underwent locking-plate osteosynthesis after open reduction between March 2005 and August 2009. According to the Mayo classification, 11 cases were classified as type IIB (61.11%) and 7 cases were classified as type IIIB (38.88%). In 7 cases, additional injuries were present in the olecranon area. We evaluated results with respect to clinical and radiologic findings. The mean follow-up duration was 22.6 months (range, 7-42 months). RESULTS Complete union was achieved in all cases. Mean union time was 4.4 months (range, 4-6 months). According to the Morrey scale, 4 cases were considered very good; 8, good; 5, fair; and 1, poor. The mean QuickDASH (Disabilities of the Arm, Shoulder, and Hand) score was 17 (range, 0-75). There were no statistically significant differences between the Mayo type IIB and type IIIB cases in terms of elbow range of motion, QuickDASH score, and Morrey score. On long-term follow-up, elbow stiffness developed in 1 patient, who underwent surgical release with simultaneous removal of the hardware. The cases with fair and poor scores were cases with open fractures and additional elbow injuries. CONCLUSIONS Locking-plate osteosynthesis is an effective and safe treatment option for comminuted olecranon fractures, allowing early joint motion and yielding satisfactory radiologic and clinical results. In cases with concomitant injuries, the risk of limited elbow motion is high.

Radiographic and functional results of osteosynthesis using the proximal femoral nail antirotation (PFNA) in the treatment of unstable intertrochanteric femoral fractures.

OBJECTIVES We evaluated the radiographic and functional results of the proximal femoral nail antirotation (PFNA) system in patients with unstable intertrochanteric femoral fractures. METHODS The study included 45 patients (25 women, 20 men; mean age 72 years; range 27 to 97 years) who underwent osteosynthesis using the PFNA for unstable intertrochanteric femoral fractures. The fractures were in the right hip in 25 patients, and in the left hip in 20 patients. The fractures were classified according to the AO system. One patient had an open fracture due to firearm injury (Gustilo-Anderson 3A). The patients underwent surgery within a mean of eight days (range 2 to 21 days) from injury. The mean hospital stay was 13.5 days (range 4 to 25 days). Closed reduction was achieved in all the patients. The results were assessed clinically and radiographically. The neck-shaft angle of the femur (collodiaphysial angle) and the tip-apex distance were measured. The position of the helical screw within the femoral head was determined using the method of Cleveland and Bosworth. Clinical evaluation was made using the Harris hip score. Perioperative and postoperative complications were recorded. The mean follow-up period was 17.3 months (range 6 to 23 months). RESULTS The mean operation time was 37.8 min (range 22 to 118 min) and the mean blood loss was 225 ml (range 150 to 450 ml). During surgery, femoral shaft fracture occurred in three patients, and greater trochanter fracture occurred in nine patients. Union was obtained in all the patients. Reduction was poor in four patients (8.9%), acceptable in seven patients (15.6%), and good in 34 patients (75.6%). The mean collodiaphysial angle was 136.7 degrees (range 125 degrees to 148 degrees). The tip-apex distance was <25 mm in 36 patients (80%), and =or>25 mm in nine patients (20%). The position of the helical screw in the femoral head was appropriate in 38 patients (84.4%). Postoperative complications included secondary varus (n=2, 4.4%), calcification at the tip of the greater trochanter (n=7, 15.5%), sensitivity over the fascia lata (n=7), medial thigh pain (n=11, 24.4%), and screw cut-out (n=1, 2.2%). Nine patients developed femoral shortness (mean 9.4 mm; range 8 to 13 mm). Screws showed lateral displacement in five patients (11.1%), which was less than 5 mm in four patients. Secondary surgery was required in four patients (8.9%). The mean Harris hip score was 77.8. Harris hip scores were very good in 11 patients (24.4%), good in 19 patients (42.2%), moderate in nine patients (20%), and poor in six patients (13.3%). CONCLUSION Due to advantages of high union rate, early postoperative mobilization, and short operation time, PFNA osteosynthesis is the method of choice for surgical treatment of unstable intertrochanteric femoral fractures..

Magnetic resonance imaging of tuberculous spondylitis.

The clinical and imaging findings of patients with a confirmed diagnosis of tuberculous spondylitis were retrospectively analyzed to assess the diagnostic value of magnetic resonance imaging (MRI) and determine the different patterns of spine involvement. Fifty-three patients with plain radiographs and MRI of the entire spinal column were included in the study. Sagittal T1- and T2-weighted MRIs of the entire spine and axial T1- and T2-weighted MRIs at the levels of interest were retrospectively evaluated. Plain radiographic correlation was obtained in all patients. The lower thoracic and thoracolumbar spine was the most commonly involved region. Magnetic resonance imaging is effective in the early diagnosis of tuberculous spondylitis. It also detects lesions, which may not be apparent on plain radiographs.

Long-term radiographic complications following treatment of unstable intertrochanteric femoral fractures with the proximal femoral nail and effects on functional results

OBJECTIVES We aimed to evaluate radiographic complications occurring after treatment of unstable intertrochanteric hip fractures with the Proximal Femoral Nail (PFN) and their effect on functional results. METHODS The study included 35 patients (23 women, 12 men; mean age 71 years; range 62 to 111 years) who were treated with the PFN for unstable intertrochanteric hip fractures. According to the AO classification, there were 12 type AII-1, 12 AII-2, 3 AII-3, 3 AIII-1, 5 AIII-3 fractures. The mean time to surgery was 13 days (range 5 to 32 days). Closed reduction was achieved in 31 patients. The patients were evaluated clinically (Harris hip score) and radiographically after a mean follow-up of 32.4 months (range 26 to 52 months) and complications were recorded. RESULTS Reduction was assessed as good or acceptable in all the patients. The mean tip-apex distance was measured as 24.2 mm (range 16 to 40 mm). Complete union was achieved in all but two patients. The mean Harris hip score was 82.1. The results were excellent in 11 patients (31.4%), good in 15 patients (42.9%), fair in seven patients (20%), and poor in two patients (5.7%). Radiographic complications mainly included secondary varus displacement in nine patients (25.7%), and calcification at the tip of the greater trochanter in two patients (5.7%). Secondary varus displacement was due to cut-out of the proximal screws (n=2), screw loosening due to collapse of the fracture site (n=2), and reverse Z-effect (n=5). Clinical results were good in two patients with calcification at the tip of the greater trochanter. Of nine patients with secondary varus displacement, the results were excellent or good in six patients, fair in two patients, and poor in one patient. Five patients (14.3%) required a subsequent operation. CONCLUSION The correct position of the osteosynthesis material and use of an intramedullary nail providing a stronger fixation of the proximal part may reduce mechanical complications following the treatment of unstable intertrochanteric hip fractures.

Effect of diclofenac sodium on union of tibial fractures in rats

Nonsteroidal anti-inflammatory drugs are often used for 7 to 10 days after fracture because of their effects on bone metabolism. This study evaluated the effect of diclofenac sodium, administered at clinical dosage and duration, on bone union. Fifty-four male Wistar rats were randomly and equally divided into three groups: control, diclofenac 1 mg, and diclofenac 2 mg. Closed diaphyseal fractures were induced in the right tibias of all rats; the two diclofenac groups received intramuscular injections in the contralateral hips for 10 days. All animals were immobilized in circular casts on the upper thighs. Six rats in each group were sacrificed at weeks 2, 4, and 6, and bony union was evaluated clinically, radiologically, and histologically. At the end of 2 weeks, clinical examinations showed subjective differences between the two treated groups and control animals, with more stable callus formation in controls. Radiologic evaluation of the callus showed numeric, but not significant, differences between control and treated animals. At 4 and 6 weeks, clinical and radiologic findings were comparable among groups. Histologically, no significant differences in callus formation were evident at any evaluation.

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.

Primary replacement of the humeral head in iatrogenically displaced fracture-dislocations of the shoulder: a report about six cases.

Dislocation of the shoulder is a common injury and may be associated with a variety of complications. We report six cases of primary replacement of the humeral head where closed reduction of a shoulder dislocation associated with an undisplaced fracture of the humeral neck led to displacement of the neck fracture. All dislocations examined were anterior with a displaced greater tubercle fracture. The patients had undergone closed reduction at other medical centres and were referred to us because of iatrogenically displaced fracture-dislocations of the shoulder. Three were women and three were men with a mean age of 52.8 years (range 38-72). Primary replacement of the humeral head was done in an average of 9.3 days (range 2-30 days) following the injury. The average follow-up period was 30.2 months (range 12-55 months). Postoperative pain, active range of motion and function were evaluated with the American Shoulder and Elbow Surgeons Criteria. The forward flexion averaged 124 degrees, active external rotation averaged 29 degrees and internal rotation (achieved movement) to the second lumbar vertebra. Because of the high risk of avascular necrosis and severe collapse of the humeral head, we conclude that the primary replacement of the humeral head is the superior treatment option in iatrogenically displaced fracture dislocations of the shoulder.

The results of open reduction and screw or K-wire fixation for isolated type II radial head fractures

OBJECTIVES We evaluated the functional and radiographic results of patients treated with open reduction and screw or K-wire fixation for isolated Mason type II radial head fractures. METHODS The study included 21 patients (14 men, 7 women; mean age 36 years; range 25 to 58 years) who were treated with open reduction followed by mini screw (n=11) or K-wire (n=10) fixation for isolated type II radial head fractures. Functional results were evaluated using the modified Morrey functional rating index. Radiographically, osteoarthritis or heterotopic ossification were investigated. The mean follow-up was 30.5 months for K-wire fixation, and 32.1 months for screw fixation. RESULTS Union was achieved in all the patients, within a mean of 6.2 weeks with screw fixation, and 5.8 weeks with K-wire fixation. The range of motion of elbow flexion-extension and pronation-supination were 131.4 degrees and 144.4 degrees with screw fixation, and 127.5 degrees and 146.5 degrees with K-wire fixation, respectively. The mean Morrey index was 94.5 (range 73 to 100) with screw fixation, yielding excellent or good results in 10 patients. One patient whose result was fair had a 2-mm step-off on the joint surface, resulting in osteoarthritis. The mean Morrey index was 92.1 (range 73 to 100) in the K-wire group, with excellent or good results in nine patients, and fair in one patient. All the patients returned to preinjury work in a mean of 11.7 weeks and 12.5 weeks in screw and K-wire groups, respectively. Heterotopic ossification was not observed. The two fixation groups were similar with respect to union time, joint range of motion, Morrey score, and time to return to work (p>0.05). CONCLUSION Our results suggest that both methods provide sufficient fixation resulting in similar functional results in isolated type II radial head fractures.

The results of surgical treatment for posttraumatic heterotopic ossification and ankylosis of the elbow

OBJECTIVES Heterotopic ossification which may develop following elbow injuries or elbow surgery may result in complete loss of elbow functions. We evaluated the results of surgical treatment for ankylosis of the elbow due to posttraumatic heterotopic ossification. METHODS The study included seven patients (6 males, 1 female; mean age 36 years; range 23 to 55 years) who developed heterotopic ossification and ankylosis of the elbow joint following surgical treatment of high-energy fractures in the circumference of the elbow. Two patients had comminuted olecranon fractures and elbow luxation, and five patients had comminuted intra-articular distal humeral fractures. Three patients had open fractures. Involvement was in the right elbow in two patients, and in the left elbow in five patients. One patient was monitored and treated in the intensive care unit for head trauma for 22 days. Initially, six patients were treated with plate osteosynthesis and one patient with tension band wiring. Foci of heterotopic ossification were detected on the radiographs taken after a mean of 24 days (range 20 to 32 days) following surgical treatment of fractures. The patients were followed-up with conventional radiography and scintigraphy for a mean of 11 months (range 7 to 15 months) before surgical treatment, during which functional loss in elbow joint movements deteriorated and ankylosis developed. All the patients had Hastings type IIIC ankylosis and poor Mayo elbow performance scores (mean score 50.7). A posterior incision was used in three patients, and a double-column incision was used in four patients. At surgery, the ulnar nerve and the lateral and medial collateral ligaments were preserved, and a posterolateral capsular release, removal of heterotopic ossification, purging of the olecranon fossa, and resection of the tip of the olecranon were performed. After completion of capsular release, cartilage pathologies were evaluated. Four patients were found to have no definite cartilage damage, whereas in three patients the joint cartilage was seriously damaged. At final controls, the patients were assessed with the Mayo elbow performance score. The mean follow-up period was 23.4 months (range 10 to 36 months). RESULTS In all cases, the range of motion and stability of the elbow joint were controlled and were found to be complete and stable at the end of the operation. At final controls, the Mayo elbow performance scores were good in three patients, moderate in one patient, and poor in three patients. All the patients with a poor elbow score had severe joint cartilage damage intraoperatively. CONCLUSION Patients who develop heterotopic ossification and ankylosis of the elbow following trauma or elbow surgery may benefit from removal of heterotopic ossification foci and elbow relaxation procedures provided that there is not severe damage to the articular cartilage.

Unrecognized Anterior Compartment Syndrome Following Ankle Fracture Surgery A Case Report

A 35-year-old male sustained a lateral malleolar fracture while playing football. The fracture was treated by open reduction and internal fixation with a tourniquet. The next day, the patient returned with pain and swelling of the ankle and was admitted again to the hospital with a suspected diagnosis of cellulitis. Ten hours later, the patient developed the symptoms of anterior compartment syndrome. Emergency open fasciotomy of the anterior compartment was performed. The retrospective analysis of the patients history was suggestive of a predisposition to an exercise-induced compartment syndrome. We think that exertional increase of the compartmental pressure before the injury and the tourniquet used during surgery contributed together to the development of compartment syndrome. Physicians should be vigilant in identifying the features of compartment syndrome when managing patients injured during a sporting activity.