Ugur Gunel

Comparison of knee function after antegrade and retrograde intramedullary nailing for diaphyseal femoral fractures: results of isokinetic evaluation.

Objective: To evaluate knee function in patients having femoral diaphyseal fractures treated with antegrade or retrograde intramedullary nail insertion. Design: Prospective. Setting: Level I referral center. Patients and Methods: Seventy patients having 71 OTA 32 fractures were randomly allocated into 2 groups to be treated with either antegrade or retrograde intramedullary nails inserted with reaming. Intervention: Antegrade nail in 41 fractures and retrograde femoral intramedullary nails in 30 fractures. Main Outcome Measures: Postoperative knee range of motion, Lysholm Knee Score, and isokinetic knee muscle function testing at least 6 months after documented fracture healing, minimum 1 year postoperatively. Results: Groups had similar data with regard to demographics and injury patterns. Mean follow-up time was 44 (range: 25-80) months. Mean knee flexion angle was 132 and 134 degrees, and mean Lysholm Score was 84 and 83.1 in antegrade and retrograde groups, respectively (P = 0.893 and P = 0.701). Isokinetic evaluation revealed similar results for peak torque deficiencies at 30 and 180 degrees per second and total work deficiencies at 180 degrees per second (P > 0.05). Age affected the knee functioning as the higher the age of the patient is, the lower the Lysholm Score and knee flexion angle (r = −0.449, P = 0.0321 and r = −0.568, P = 0.001, respectively). Conclusions: Knee function seems to have similar clinical results after either antegrade or retrograde nail insertion for femoral diaphyseal fractures when knee range of motion, Lysholm Scores, and isokinetic knee evaluation are considered as outcome measures. With increasing patient age, a decrease in knee functioning should be anticipated in patients with femoral fractures treated with intramedullary nails regardless of technique.

Alternative reliable techniques in femoral torsion measurement.

The clinical and conventional bi-planar determinations of femoral torsion were compared with the tomographic technique, the reliability of which was confirmed. Femoral torsions were measured with the trochanteric prominence angle test, the sinus-wave bi-planar conventional radiographic technique, the modified Hermann bi-planar conventional radiographic technique and the limited three-dimensional volumetric tomography technique in 34 femora of 17 patients. There was a strong correlation between the modified Hermann and the limited tomography techniques for 14 intact and 20 fractured femora. If limited three-dimensional volumetric tomography cannot be obtained, the modified Hermann bi-planar conventional radiographic technique must be used in patients who have scarring about the proximal femur and obesity. Otherwise use of the trochanteric prominence angle test is much more cost-effective and is as accurate as the limited three-dimensional volumetric tomography technique.

An alternative fixation method for the treatment of unstable distal clavicle fractures: locked distal radius plate

OBJECTIVES Optimal surgical fixation method for displaced distal clavicle fractures should not impose limitations on neighboring joint movements. We evaluated the results of surgical treatment of displaced distal clavicle fractures using locked distal radius plates. METHODS Displaced distal clavicle fractures of 14 consecutive patients (11 men, 3 women; mean age 30 + or - 9 years; range 19 to 51 years) were treated using open reduction and locked distal radius plates. Before final fixation, one patient underwent K-wire fixation with tension band at another center, resulting in nonunion. Except for two cases with late presentation, the mean time to surgery was 5.3 days (range 1 to 17 days). According to the Neer classification, fresh fractures were type II in 10 patients and type III in three patients. Shoulder examinations and functional evaluations were made at 3, 6, and 12 months postoperatively. Functional assessment included the Modified Shoulder Rating Scale and Constant score. RESULTS All patients achieved full range of motion of the shoulder at six weeks postoperatively. The mean modified shoulder score was 18.7 + or - 1.5 and the mean Constant score was 95.4 + or - 3.0 at 12 months. None of the patients developed implant failure, loss of reduction, skin breakdown, or infection. CONCLUSION In selected acute fractures and nonunions of the distal clavicle, excellent clinical results are easily achievable with locked distal radius plate fixation because it allows early shoulder movements without necessitating implant removal.

Ochronosis: complicated tear of black meniscus

We describe a case of a previously healthy 35-year-old man who presents with meniscal symptoms, and present the arthroscopic findings of a complicated tear of black lateral meniscus. Investigations revealed that he had underlying alkaptonuria, which was previously undiagnosed without any other findings. After the surgical treatment, the patient’s complaints were alleviated and almost no complaints were registered, during the next follow-up.

Combined surgical treatment for missed rupture of triceps tendon associated with avulsion of the ulnar collateral ligament and flexor-pronator muscle mass

Triceps tendon ruptures are rare injuries. Coexistence of ipsilateral ulnar collateral ligament injury is even rarer. Here, we describe an unusual combination injury to elbow of a 39-year-old male construction worker consisting of triceps tendon rupture, avulsion of elbow ulnar collateral ligament and flexor pronator muscle origin ipsilaterally. A simultaneous repair and reconstruction of all damaged structures was proposed with individualized postoperative rehabilitation. Return to pre-injury level of activities obtained with this treatment protocol. High degree of suspicion and careful examination were needed to prevent missed diagnosis and prolonged instability which may be inevitable after inappropriate treatment of such injury.

Results of triple arthrodesis: effect of primary etiology

BackgroundSevere disability originating from feet generally requires surgery. In addition to a number of other techniques, triple arthrodesis is still used to treat deformity and instability unresponsive to conservative measures. The aim of this study was to evaluate the results of the triple arthrodesis operation in two groups of patients with different primary etiologies and to identify the possible factors affecting the results.MethodsDuring a 4-year period, triple arthrodesis was performed on 25 feet in 20 patients (average age 24.9 years). These patients were divided into two groups according to the primary etiology of the disability: neurogenic and nonneurogenic. Patients were evaluated with pre-and postoperative clinical examinations, American Orthopedic Foot and Ankle Society (AOFAS) Hindfoot and Ankle Scale, radiography, pedobarography, and a general health questionnaire (Short Form 36, SF-36). The need for orthotics and the effect of previous treatments on the end results were also evaluated.ResultsThe preoperative average AOFAS score improved from 24 to 71 postoperatively. Preoperative AOFAS values of neurogenic cases were significantly lower than those of nonneurogenic cases. Postoperative AOFAS values were found to be lower in neurogenic cases (64.0 vs. 77.6). Marked improvement was observed for all angular measurements. No relation was found between the AOFAS, changes in angular measurements, and pre-and postoperative plantar pressure analysis results. SF-36 results improved postoperatively in both groups. Triple arthrodesis decreased the use of orthotics postoperatively in both groups. Previous treatments were not found to affect the end results in this series.ConclusionsTriple arthrodesis operation is a surgical option with limited alternatives in patients with disabilities originating from feet. Both neurogenic and nonneurogenic patient groups improved significantly, and we were unable to show any significant differences in the results of these two groups.

Acetabular index values in healthy Turkish children between 6 months and 8 years of age: a cross-sectional radiological study

Objective: The aim of this study was to determine the normal acetabular index values in children between 6 months and 8 years of age based on sex, age and side and to define the cutoff values for mild and severe acetabular dysplasia. Methods: The records collected from the data pool that was gathered to define the prevalence of untreated congenital hip dislocation in Turkish children between 6 months and 14 years of age was used. The acetabular index was measured on pelvic and abdominal radiographs of children between 6 months and 8 years of age, taken in 19 different cities for non-dysplasia related causes. The distribution of the index values based on age, sex and side. Results: Thirty-three hips of 21 children (0.75%) out of 2788 children were found to be subluxated or luxated. Acetabular index values of 5534 hips of 2767 children were measured. Acetabular index values of 723 (13%) hips of 493 children (17.8%) were found to be between 1 and 2 standard deviations. Acetabular index values of 147 hips (2.65%) of 118 children (4.3%) were calculated to be above 2 standard deviations. There was a negative correlation between the acetabular index and age. Conclusions: The study defines the normal acetabular index values in healthy Turkish children between 6 months and 8 years of age and the expected acetabular index values for mild and severe dysplasia.

An unusual cause of forefoot pain: diagnosis and discussion

Osteoid osteoma is a relatively uncommon osteoblastic lesion of the bone that accounts for approximately 10% of all benign bone tumors and occurs predominantly in children and young adults, with a male-to-female ratio of 3:1 [1, 2]. More than half of osteoid osteomas occur in the femur and tibia, and the proximal femur is by far the most common location [2]. Its incidence in the small bones of the foot ranges from 2% to 11%, with the talus being the most common site of pedal involvement [2, 3]. No case specifically involving the fibular sesamoid has been reported in the literature. Except for its location, this case presents a classic history of OO, occurring in a 19-year-old woman and producing nighttime pain, relieved to some extent by salicylates. The classic presentation is a single small (<1.5 cm) round or oval lytic focus, which may contain a variable amount of ossification with a zone of reactive sclerosis [4]. The radiographic appearance of OO may be classified according to its location into cortical, cancellous, and subperiostal regions of bone [1, 5–7]. Typically, the tumor is cortical , comprising a small area of radiolucency less than 1 cm in diameter, subcortically placed, and associated with dense adjacent bone sclerosis and periostal reaction. The cancellous variety of OO displays less radiographic sclerosis than does the cortical type. The cancellous and subperiostal varieties have been reported to be more prevalent in the small bones of the hand and foot [7]. In our case there was a radiolucent nidus surrounded by an illdefined sclerotic rim, with central calcification as in the cancellous subtype. In patients with OO computed tomography demonstrates the radiolucent nidus with a smooth inner surface, and, in some cases, a radiodense center can be visualized, as in our case. This central calcification is suggested to represent the osteoblastic center of the lesion [8]. Bone scanning almost always produces positive findings and is valuable when plain radiographs are equivocal. A typical ‘hot spot’ is shown, due to intense radionuclide uptake by the lesion, as in our case [9]. The histopathologic appearance of the nidus may vary, depending on the maturity of the lesion [2]. The pathologic appearance of the nidus is of a small, round, mass of tissue which can be either soft or sclerotic, red, and surrounded by normal or sclerotic bone. Microscopic Skeletal Radiol (2009) 38:831–832 DOI 10.1007/s00256-009-0711-0

Intracompartmental pressure changes after anterolateral bridge plating of tibial fractures.

OBJECTIVE Compartment syndrome is one of the most devastating complications in orthopedics both for the patient and the treating physician. Among the many causes, trauma and its treatment are the most common reasons for compartment syndrome, which most frequently occurs in the lower leg following tibial fractures. Since bridge plating of difficult metadiaphyseal tibial fractures is becoming increasingly popular, serious concerns have been raised about the increased intracompartmental pressures and possible compartment syndrome. METHODS This study investigated the intracompartmental pressure changes in anterolateral compartment of the leg during and immediately after anterolateral bridge plating of tibial fractures. Intracompartmental pressures were measured before and during plate application, just after the completion of fixation, and immediately and 4-5 min after the tourniquet release in 22 isolated closed comminuted tibial fractures. RESULTS Baseline anterolateral compartment pressures were higher than those on the uninjured side (9.3 vs 27.8 mmHg). Pressures were 69.5, 57.4, 65.8, and 56.8 mmHg, respectively, for the other measurements times. None of the patients received prophylactic fasciotomy, and none developed clinical compartment syndrome. CONCLUSION We found that anterolateral compartmental pressures were higher than pressures on the uninjured side in all patients. Although there is a considerable increase in intracompartmental pressures during and immediately after anterolateral percutaneous bridge plating of comminuted tibial fractures, intraoperative prophylactic fasciotomy is not routinely needed. One should monitor the patients on the first postoperative day for signs of compartment syndrome. Fasciotomy decisions should be based on both clinical symptoms and serial intracompartmental pressure measurements rather than a single measurement.

Long-term follow-up of a hip joint osteoblastoma after intralesional curettage and cement packing: a case report

This article reports a case of intraarticularly expanding benign osteoblastoma of the acetabulum caused femoral head destruction by impingement in a 17-year-old male that was diagnosed for two years from the onset of symptoms. As a treatment, by surgical dislocation of the hip joint, polymethyl-methacrylate was packed inside the gap of the acetabular site after intralesional wide curettage. Femoral head remodeling was observed without recurrence after ten years follow-up.