Serdar Toker

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..

Topical Atorvastatin in the Treatment of Diabetic Wounds

Background:Currently, it is reported that statins may be useful in the treatment of diabetes mellitus foot ulceration. The aim of this study was to evaluate treatment of the wounds in streptozotocin-induced diabetic rats with local atorvastatin. Methods:Two 15 × 15 mm-sized wounds were created in 28 streptozotocin-induced rats. A total of 56 diabetic wounds were studied in 8 groups (n = 7). No treatment was administered in the first and second groups, which lasted for 7 and 14 days, respectively. Third and fourth groups consisted of diabetic rats that were administered 1:1 mixture of lanolin and vaseline therapy for 7 and 14 days, respectively. One percent statin plus 1:1 mixture of lanolin and vaseline was used in the fifth and sixth groups for 7 and 14 days, respectively; and in seventh and eighth groups, 5% statin plus 1:1 mixture of lanolin and vaseline therapy was used for 7 and 14 days, respectively. On the 7th and 14th days, state of the wound healing was observed, and the percent of wound healing was determined by measuring its size and by performing a histopathologic study. The statistical analyses were performed by Mann–Whitney U test, using SPSS 14.0 software. Results:On the 14th day, the rates of wound healing in the first, second, third, and fourth groups were 14%, 40%, 96.59%, and 96.51%, respectively. This ratio was calculated by the formula healing ratio (%) = 100 × (1−wound area/initial wound area). Accordingly, in the multiple comparisons, the rates of wound healing were found to be significantly higher in the diabetic rat groups administered 1% and 5% atorvastatin compared with those administered a mixture of lanolin-vaseline and the untreated group (for comparison each one P < 0.001). Conclusions:Local atorvastatin therapy may be useful for healing the wounds in diabetic rats. Further clinical and experimental studies are needed to confirm these results.

Analysis of risk factors affecting mortality in elderly patients (aged over 65 years) operated on for hip fractures

OBJECTIVES We analyzed the relationship between mortality rates and preoperative medical conditions and vital factors in elderly patients (aged over 65 years) operated on for hip fractures. METHODS The study included 92 patients (56 females, 36 males) who were operated on for hip fractures and had follow-up data up to 36 months. The mean age was 76 years (range 65 to 96 years) for women, and 74 years (range 65 to 92 years) for men. The fractures were intertrochanteric in 54 patients (58.7%), and in the femur neck in 38 patients (41.3%). The patients were divided into three risk groups, namely, low (n=23, 25%), moderate (n=45, 48.9%), and high (n=24, 26.1%), according to our institutional Sişli Etfal risk factor assessment scale. Relationships were analyzed between mortality and sex, preinjury ambulation level, cognitive functions, and time to surgery in each risk group. RESULTS One-year mortality rates were 6.9%, 31.4%, and 80% in low-, moderate-, and high-risk groups, respectively. The risk scores were significantly correlated with mortality rates (r=0.664; p<0.05). Thirty-four female patients (60.7%) and 18 male patients (50%) were dead at the end of 36 months. No significant relationship was found between mortality rates and sex, cognitive functions, and time to surgery (p>0.05). Mortality within the first three postoperative months among patients who could only ambulate with a walker preoperatively was significantly higher than those who could walk independently or with an aid (p=0.037). CONCLUSION A risk assessment system covering all risk factors to estimate postoperative mortality following surgery for hip fractures would be helpful in planning treatment.

Extension Block Pinning Versus Hook Plate Fixation for Treatment of Mallet Fractures

PURPOSE To compare the outcomes and associated costs of the treatment of mallet fractures with either extension block pinning or open reduction and hook plate fixation. METHODS We treated 22 patients for a mallet fracture that involved at least 25% of the distal phalanx articular surface. Three joints demonstrated concomitant volar subluxation. Extension block pinning was used to treat 16 fractures (group 1) and 6 were treated with open reduction and hook plate fixation (group 2). All patients were evaluated at the second, fourth, and sixth weeks after surgery. Collected data included range of motion, extensor lag, and pain status. Patients were asked to grade preoperative and postoperative pain levels on a visual analog scale. Functional outcomes were determined by Crawford criteria. We retrospectively performed a cost analysis using our institutional records. RESULTS Mean follow-up was 12.7 months. Visual analog scale pain scores improved by a similar amount for both groups. Preoperative pain scores were 7.0 for group 1 and 7.5 for group 2. Postoperative levels were 2.0 and 2.0, respectively. Mean extensor lag was identical for both groups, 5°. Mean flexion was 70° for group 1 and 80° for group 2. Based on the Crawford criteria, group 1 had 5 patients rated as excellent, 6 as good, 3 as fair, and 2 as poor. Group 2 outcomes were 2 excellent, 2 good, and 2 fair. Five complications occurred in group 1, and 1 in group 2. Differences noted between groups were not statistically significant. Extension block pinning was more cost-effective than hook plate fixation. CONCLUSIONS We find extension block pinning to be an equally effective but more cost-efficient treatment than open reduction and hook plate fixation. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

Desflurane anaesthesia in a patient with multiple sclerosis in total hip replacement

Multiple sclerosis (MS) is a progressive demyelinating disease presenting with a relapsing-remitting course and affects large areas of the brain and the spinal cord. Surgical stress often induces exacerbation of MS symptoms. It is mandatory to prepare the MS patient very carefully for the surgery and anaesthesia with an effective premedication and an effective postoperative analgesia following a safe and minimal-risk anaesthesia management. In recent reports, results of general and regional anaesthesia in MS patients have been discussed. To our knowledge this is the first case report of the use of desflurane anaesthesia in a patient with MS. In conclusion, desflurane anaesthesia is a safe and useful method for MS patients.

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.

Isolated Fracture of the Coracoid Process

Coracoid fractures are rarely seen fractures. In the shoulder girdle, coracoid process fractures generally accompany dislocation of the acromioclavicular joint or glenohumeral joint, scapula corpus, clavicula, humerus fracture, or rotator cuff tear. Coracoid fractures can be missed and the treatment for coracoid process fractures is still controversial. In this paper, a 34-year-old male manual labourer presented to the emergency department with complaints of pain and restricted movement in the left shoulder following a traffic accident. On direct radiographs and computerised tomography images a fragmented fracture was observed on the base of the coracoid process. In addition to the coracoid fracture, a mandibular fracture was determined. The patient was admitted for surgery on both fractures. After open reduction, fixation was made with a 3.5 mm cannulated screw and washer. At the postoperative 6th week, bone union was determined. The patient returned to his previous occupation pain-free and with a full range of joint movement. In conclusion, in the current case of isolated fragmented coracoid process fracture showing minimal displacement in a patient engaged in heavy manual work, surgery was preferred as it was thought that nonunion might be encountered particularly because of the effect of forces around the coracoid.

A calcaneal osteochondroma with recurrence in a skeletally mature patient: a case report

IntroductionOsteochondroma is the most common benign tumor of the skeleton. However, calcaneal osteochondroma is very rare. Osteochondromas grow during childhood through adolescence, but usually growing ends when the epiphyseal plates close. In an adult, growth of an osteochondroma suggests the diagnosis of malignant transformation to a chondrosarcoma. However, enlargement of an osteochondroma reported as benign after skeletal maturity is present in literature.Case presentationWe report the clinical and radiologic findings of a calcaneal osteochondroma with an extremely rare placement and painfull, rapid reccurence following surgical excision in a skeletally mature female. The lesion showed growth the first-operation later and was re-operated. Histopathological examination did not show malignancy.ConclusionIt should kept in mind that benign osteochondromas can show symptomatic growth in skeletally mature patients without malignant transformation.

Transverse Carpal Ligament and Forearm Fascia Release for the Treatment of Carpal Tunnel Syndrome Change the Entrance Angle of Flexor Tendons to the A1 Pulley: The Relationship between Carpal Tunnel Surgery and Trigger Finger Occurence

Purpose. The appearance of trigger finger after decompression of the carpal tunnel without a preexisting symptom has been reported in a few articles. Although, the cause is not clear yet, the loss of pulley action of the transverse carpal ligament has been accused mostly. In this study, we planned a biomechanical approach to fresh cadavers. Methods. The study was performed on 10 fresh amputees of the arm. The angles were measured with (1) the transverse carpal ligament and the distal forearm fascia intact, (2) only the transverse carpal ligament incised, (3) the distal forearm fascia incised to the point 3 cm proximal from the most proximal part of the transverse carpal ligament in addition to the transverse carpal ligament. The changes between the angles produced at all three conditions were compared to each other. Results. We saw that the entrance angle increased in all of five fingers in an increasing manner from procedure 1 to 3, and it was seen that the maximal increase is detected in the middle finger from procedure 1 to procedure 2 and the minimal increase is detected in little finger. Discussion. Our results support that transverse carpal ligament and forearm fascia release may be a predisposing factor for the development of trigger finger by the effect of changing the enterance angle to the A1 pulley and consequently increase the friction in this anatomic area. Clinical Relevance. This study is a cadaveric study which is directly investigating the effect of a transverse carpal ligament release on the enterance angle of flexor tendons to A1 pulleys in the hand.

Klippel–Feil syndrome with osteopoikilosis in a young lady and her four female relatives with osteopoikilosis

Osteopoikilosis is a rare, usually asymptomatic, autosomal dominant bone disorder, which is usually found incidentally on X-ray. Klippel–Feil syndrome is a rare disorder characterized by the congenital fusion of any two of the seven cervical (neck) vertebrae. It is caused by a failure in the normal segmentation or division of the cervical vertebrae during the early weeks of fetal development. In this case report, we describe a woman with osteopoikilosis associated with type 2 Klippel–Feil syndrome. Additionally, four female members of her family had osteopoikilosis. We state that possible syndromes that can go with osteopoikilosis must be kept in mind in case of an incidental diagnosis in daily practice.