Umut Yavuz

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.

Isolated subtalar fusion for neglected painful intra-articular calcaneal fractures

OBJECTIVE The objective of this study was to evaluate the radiological and clinical outcomes of treatment of subtalar arthrodesis in patients developing talocalcaneal arthrosis secondary to intra-articular calcaneal fractures. METHODS The study included 20 patients (21 feet) who underwent subtalar arthrodesis due to symptomatic subtalar arthrosis following conservative treatment for intra-articular calcaneal fracture between 2005 and 2011. Autograft or allograft was used in 11 patients. Patients were evaluated clinically using the American Orthopedic Foot and Ankle Society (AOFAS) ankle hindfoot score. Hindfoot alignment, quality of subtalar fusion and arthritis occurring in other joints were used for the radiological evaluations. RESULTS Mean duration of follow-up was 43 (range: 21 to 83) months. Mean preoperative AOFAS score was 61.7 (range: 40 to 67) and mean postoperative AOFAS score was 84.2 (range: 65 to 94). The difference between scores was statistically significant (p=0.001). Six patients had excellent, 8 good and 6 fair results. Complete fusion was achieved in 19 patients (20 feet). In 2 patients, arthritic changes were radiologically observed in the midtarsal joints. These changes were not symptomatic. There were no statistically significant differences between pre- and postoperative radiological measurements. No patients experienced malunion. CONCLUSION While subtalar arthrodesis appears to provide radiological and clinical benefits, it may cause moderate and asymptomatic osteoarthritis in the midtarsal joints.

Perioperative versus postoperative measurement of Taylor Spatial Frame mounting parameters

OBJECTIVE The aim of this study was to determine the differences, if any, between application parameters for the Taylor Spatial Frame (TSF) system obtained during surgery under fluoroscopy and after surgery from digital radiography. METHODS This retrospective study included 17 extremities of 15 patients (8 male, 7 female; mean age: 21.9 years, range: 10 to 55 years) who underwent TSF after deformity and fracture. Application parameters measured by fluoroscopy at the end of surgery after mounting the fixator were compared with parameters obtained from anteroposterior and lateral digital radiographs taken 1 day after surgery. RESULTS Fixator was applied to the femur in 8 patients, tibia in 6 and radius in 3. Mean time to removal of the frame was 3.5 (range: 3 to 7) months. Mean perioperative anteroposterior, lateral and axial frame offsets of patients were 9.1 (range: 3 to 20) mm, 18.1 (range: 5 to 37) mm and 95.3 (range: 25 to 155) mm, respectively. Mean postoperative anteroposterior, lateral and axial frame offset radiographs were 11.8 (range: 2 to 30) mm, 18 (range: 6 to 47) mm and 109.5 (range: 28 to 195) mm, respectively. There was no statistically significant difference between the groups (p>0.05). CONCLUSION While measurements taken during operation may lengthen the duration in the operation room, fluoroscopy may provide better images and is easier to perform than digital radiography. On the other hand, there is no difference between measurements taken during perioperative fluoroscopy and postoperative digital radiography.

Flexion-adduction-external rotation method for shoulder dislocations

OBJECTIVE The aim of this prospective study was to assess the effectiveness of the flexion-adduction-external rotation method in the reduction of acute anterior shoulder dislocations. METHODS The study included 128 patients (98 male, 30 female; mean age: 33, range: 19 to 81) with a history of acute anterior shoulder dislocation treated with the flexion-adduction-external rotation method. Neurovascular examination was performed before and after reduction. Reduction duration and patient responses regarding the reduction method were recorded. RESULTS First-time dislocation occurred in 92 patients and recurrent dislocation in 36. 111 patients had subcoracoid dislocations and 17 subglenoid dislocations. Fracture of the greater tubercle was present in 13 patients. Reduction was achieved in the first attempt in 104 patients and in the second in 12 patients. Mean reduction time was under 1.5 (range: 0 to 5) minutes. Reduction was unsuccessful in 12 patients and reduction under general anesthesia was performed. No patients experienced neurovascular injury after reduction. CONCLUSION The forward flexion-adduction-external rotation method is an effective and comfortable reduction method for the treatment of shoulder dislocation or fracture-dislocation.

An Unusual Stress Fracture in an Archer with Hypophosphatasia

We report a 45-year-old male archer with stress fracture in his left ulna on the background of adult type of hypophosphatasia. The patient presented to several medical centers for pain around the left elbow and received medical treatment upon diagnosis of tenosynovitis. History of the patient revealed that he had had diagnosis of hypophosphatasia ten years ago and underwent percutaneous screwing for stress fracture on both of his femoral necks. Upon finding nondisplaced stress fracture on proximal metaphysis of the ulna on X-ray, the patient underwent magnetic resonance imaging (MRI) in order to exclude pathological causes. No additional pathology was observed in MRI scanning. The patients sportive activities were restricted for 6 weeks and he received conservative management with arm slings. Adult type of hypophosphatasia is a disease manifesting with widespread osteoporosis and presenting with low serum level of alkali phosphatase (ALP). Stress fracture should definitely be considered in the patients with history of hypophosphatasia and refractory extremity pain.

A novel biological reconstruction of tibial bone defects arising after resection of tumors.

The purpose of this paper is to describe a biologic reconstruction strategy for defects after resection of malignant tibia tumors. Limb-sparing surgery was used for 4 patients with malignant tibia tumors. All patients were male, with an average age of 39.5 years (range: 34-46 years). Mean length of the resected tibia segment was 135 mm (range: 120-150 mm). The defects were primarily reconstructed with bone cement and locked plate until completion of the medical treatment of the tumor. The bone transport was made through locked plate, and the docking site was grafted at the final stage. Mean follow-up period was 49.75 months (range: 71-22 months). Mean distraction index was 1148 mm/days (range: 1130-1175 mm/days), and mean external fixation time was 167 days (range: 152-187 days). According to Paley, functional results were excellent in 2 cases and good in the other 2 cases. Radiological results were excellent in all cases. Two major and 2 minor complications were observed. In this method, stable internal fixation and active usage of extremities are provided until biological reconstruction, and possible wound problems can be completely eliminated during the duration of medical treatment of the tumor.

Salter innominate osteotomy in the treatment of late presentation Perthes disease

Purpose The aim of this study was to evaluate the clinical and radiological results of patients presenting older than eight years and treated with Salter osteotomy for Perthes disease. Method Seventeen patients (18 hips) with late presentation of Perthes disease treated with Salter osteotomy. Sixteen males were identified. The average age of patients was 8.8 years (range 8-12). Preoperation radiographs were analysed for lateral pillar staging, centre-periphery (CP) angle, Sharp acetabular index, acetabular depth index, acetabular covering percentage and Cross-over sign. Final follow-up radiograph were classified using modified Stulberg grade. Results The average follow-up of the patients was 78 months (range 40-104). During the surgery, seven hips were found to be lateral pillar grade B, three hips grade B/C and 8 hips grade C. In the final examination, 10 hips were evaluated as good (Stulberg 1 or 2), seven as medium (Stulberg 3) and one as bad (Stulberg 4). There was shortening in four patients who were all either Stulberg stage 3 or 4. A meaningful difference was detected between the pre-operation and post-operation radiographic values, regardless of the surgical staging. However, no statistical difference was found between the patients in Stulberg stage 3 or 4 and stage 1 or 2 for radiographic variables. Conclusion Salter osteotomy can be used to treat older patients with lateral pillar stage B, B/C and C at presentation.

Single-Stage Treatment of Aseptic Nonunion of the Humerus with Locking Plate Fixation and Autograft

Background: Locking and non-locking compression plates are widely used in different long bone fractures. Biomechanical and controlled studies have reported a higher stability and rate of union with the use of locking plates. Locking plates are safely used also in the treatment of humeral nonunions with varying rates of success. Aims: The aim of this study was to evaluate the radiological and clinical results of a single-stage surgical treatment with locking compression plates (LCPs) and autologous bone grafting in patients with aseptic nonunion of the humerus. Study Design: Level of Evidence IV, case control study. Methods: Twenty-four patients (17 males; mean age: 43.5 years) treated with LCPs and autologous bone grafts due to nonunion following humeral fractures were included in this study. Twelve patients had earlier been treated surgically while the remaining 12 had received non-surgical (conservative) treatment. Six patients had atrophic and 18 had oligotrophic nonunions. Functional evaluation was made using the Constant-Murley scoring system. Results: The mean follow-up period was 43.6 months. Radiological union was observed in all patients except one (95.8%) in an average period of 18.8 weeks. A mean shortening of 1.8 cm was performed on six patients with atrophic nonunion. Preoperative infection markers and intraoperative cultures were negative for infection. Four patients experienced delayed unions and one patient had transient radial nerve palsy. Ten patients had excellent, 12 had good, and two had fair scores. Conclusion: The management of humeral nonunions with single-stage surgical intervention performed using LCPs and autologous bone grafts, following adequate debridement, is an effective method with satisfactory radiological and clinical outcomes.

Simultaneous bilateral correction of genu varum with Smart frame

Purpose: The aim of this study is to evaluate clinical and radiological results of simultaneous bilateral correction of genu varum with Smart frame. Methods: Between 2011 and 2015, a total of 25 patients (10 females, 15 males) who had bilateral genu varum deformity were operated bilaterally with tibial and fibular osteotomy in the same session, using Smart frame. The mean follow-up period was 28.7 (range, 13–45) months. All patients had bilateral tibial varus deformity. Femoral deformity was corrected in an earlier session in nine patients. Mechanical axis deviation (MAD), mechanical lateral distal femoral angle, mechanical medial proximal tibial angle (mMPTA) and posterior proximal tibial angle (PPTA) were measured preoperatively and postoperatively. Short Form-36 questionnaire was filled by the patients preoperatively and during the last follow-up. Results: The mean preoperative MAD was 37.6 mm (range, 9–98 mm), which improved to 8.4 mm (range, 3–44 mm) postoperatively (p < 0.05). The mean preoperative mMPTA was 76°, which improved to 89° (p < 0.05). The mean preoperative PPTA was 75.5°, which improved to 80.3 (p < 0.05). Ten problems (20%), two obstacles (4%) and no sequelae occurred in 50 legs of 25 patients. Conclusions: In conclusion, Smart frame is an accurate and reliable method for performing bilateral simultaneous deformity correction in patients with bilateral genu varum deformity. It can be applied for various childhood-induced severe tibial deformities such as achondroplasia, rickets, skeletal dysplasia and Blount’s disease.

Percutaneous radiofrequency ablation for osteoid osteoma under guidance of threedimensional fluoroscopy.

Purpose To evaluate the outcome of percutaneous radiofrequency ablation under guidance of 3-dimensional fluoroscopy in 17 patients with osteoid osteoma. Methods Records of 11 male and 6 female consecutive patients aged 4 to 28 (mean, 13.8) years who underwent radiofrequency ablation under guidance of 3-dimensional fluoroscopy for osteoid osteoma and were followed up for a mean of 15.8 (range, 12–28) months were reviewed. All patients had been treated with analgesics but failed to achieve lasting pain relief. Visual analogue score (VAS) for pain was assessed pre- and post-operatively. Absence of pain was considered recovery. Results The mean operating time was 55 (range, 20–95) minutes, and the mean length of hospital stay was 2.8 (range, 2–7) days. The mean amount of radiation was 390.2 (range, 330.5–423.6) mGy/cm. Relief of pain occurred within the first 24 hours in 11 patients and by the end of the first week in 3 patients. Pain persisted in 3 patients at one month; they underwent revision surgery and achieved complete recovery. The mean VAS for pain was 7.2 (range, 6–9) in 17 patients preoperatively and decreased to 0.64 (range, 0–2) in the 14 patients with pain relief and 0.66 (range, 0–1) in the 3 patients after revision surgery. Two patients had severe discharge from the wound secondary to fat necrosis, which resolved within a week with antibiotics and local dressings. No patient had cellulitis, vasomotor instability, neurovascular injury, fracture, or deep infection. Conclusion Percutaneous radiofrequency ablation under guidance of 3-dimensional fluoroscopy is a viable treatment option for osteoid osteoma.