Comparison of 4 surgical approaches in pediatric Gartland type 3 supracondylar humerus fractures treated by open reduction and pinning: A multicenter study.

OBJECTIVE: This study aimed to compare the outcomes of medial, lateral, posterior, and anterior approaches in pediatric Gartland type 3 supracondylar humerus fractures treated with open reduction and pinning. METHODS: Gartland type 3 supracondylar humeral fractures treated by open reduction and pinning in 4 different centers with different surgical approaches were divided into 4 groups according to the surgical approach. Each trauma center applied the surgical approaches with which it had the most experience. Specifically, patients treated with medial, lateral, posterior, and anterior approaches were classified as groups 1, 2, 3, and 4, respectively. The demographic characteristics of the patients and the complications were compared. The findings were evaluated according to the Flynn criteria. RESULTS: A total of 198 pediatric patients, 114 (57.6%) male and 84 (42.4%) female, with a mean age of 6.27 ± 2.03 (range = 1-12) years, were included in this study. They were all treated with open reduction and pinning, 51 (25.8%) by the medial approach, 49 (24.7%) by the lateral approach, 66 (33.3%) by the posterior approach, and 32 (16.2%) by the anterior approach. No significant differences in age, gender, side, or complication status were found between the groups (P > .05). There were also no significant differences between the groups regarding the Flynn cosmetic and functional criteria (P > .05). CONCLUSIONS: Superior functional and cosmetic results can be achieved with fewer complications with surgical techniques applied by experienced surgeons in the open reduction of supracondylar humeral fractures in children. It is recommended that surgeons choose the approach with which they have the most experience. LEVEL OF EVIDENCE: Level III, Therapeutic study.

Does the ZipTightTM effective to maintain reduction after the treatment of acute acromioclavicular joint dislocation?

BACKGROUND: The present study evaluated the functional and radiographic outcomes of acute acromioclavicular (AC) joint reconstruction performed using the mini-open technique and a knotless suspensory loop device METHODS:: A total of 25 patients (20 male and 5 female patients; mean age, 30.7 years; standard deviation, 10 years; range, 17-57 years) who fulfilled the inclusion criteria were included in the study. A functional assessment was performed using the Constant and University of California Los Angeles score. The radiologic assessment included standard anterior-posterior views of the AC and coracoclavicular (CC) distances. RESULTS: The mean follow-up period was 18.6 months (range, 12-23 months). The mean Constant score was 87.2 ±â€Š3.2, and the mean University of California Los Angeles score was 30.1 ±â€Š2.4 at the final follow-up. Radiological evaluation at the last follow-up of the patients: Although there was no statistically significant increase in the AC and CC values of the patients () at the last follow-up, the average CC value in 6 (24%) of the 25 patients was greater than 50% compared with the unaffected side CC and early postoperative CC values. However, there was no statistically significant difference in the Constant and UCLA scores between the 6 patients with reduction loss and the 19 patients with reduction maintenance (P = .86). CONCLUSIONS: Clinical results of fixation of acute AC joint dislocations using the ZipTight knotless suspensory loop device system and mini-open technique were favorable in terms of functional recovery and pain relief. However, the major disadvantage of this method was radiological loss of AC joint reduction when compared to the contralateral shoulder.

Is pharmacological anticoagulant prophylaxis necessary for adolescent idiopathic scoliosis surgery?

We report the outcomes of mechanical prophylaxis and chemoprophylaxis in patients who underwent elective surgery for idiopathic adolescent scoliosis (AIS).We retrospectively studied the patients who underwent posterior spinal instrumentation for AIS. The patients were divided into three groups: Group A low-molecular-weight heparin (LMWH) started at 8 hours after surgery; Group B LMWH started at 24 hr after surgery; Group C did not receive chemoprophylaxis. The data about wound oozing, need for transfusion, preoperative and postoperative hemoglobin level, length of stay in hospital, interval from the surgery to removal of closed suction drainage tube, postoperative blood loss from closed suction drain, deep venous thrombosis (DVT), and pulmonary embolism (PE) were investigated.The mean age and Lenke classification for all the groups were similar. No DVT or PE was detected in any group. The mean blood loss from the drain was higher in Group A (400 mL) and Group B (450 mL) when compared to Group C (150 mL) (P = .001). There were more wound oozing in Groups A (5) and B (6) than in Group C (3) (P = .585). Three patients in Group B, 3 patients in Group A, and no patient in Group C had superficial infections. However, there was no statistical difference between the groups (P = .182). Postoperative hospital stay was significantly longer in Groups A (6 days) and B (6 days) then in Group C (5 days) (P = .001).Our current study claims that chemoprophylaxis is not necessary for the patients without risk factors after AIS surgery. Early mobilization and mechanoprophylaxis represents adequate prophylaxis in addition to pain management and well hydration in patients' routine treatment. The complications of chemoprophylaxis are not correlated to the initiation time of prophylaxis.

Suprapatellar approach for fractures of the tibia: Does the fracture level matter?

OBJECTIVES: This study aims to evaluate proximal, shaft, and distal tibial fractures treated with suprapatellar (SP) tibial intramedullary nailing (IMN) in terms of alignment, healing, and patellofemoral (PF) pain. PATIENTS AND METHODS: The study included 58 patients (41 males, 17 females; mean age 42.9 years; range, 18 to 75 years) treated via the SP approach in semiextention. Suprapatellar IMN surgeries were performed by two surgeons. After a minimum of 12 months of follow-up, patients' genders, ages, limb sides, fracture types, and classifications were recorded. Fracture reduction accuracy, angulation, PF arthritis, healing time, complications, and nonunions were analyzed. Anterior knee pain, visual analog scale (VAS), and Lysholm knee scoring scale were used as clinical measurements. RESULTS: Seventeen fractures were in the proximal third, while 22 were in the middle third and 19 were in the distal third of the tibia. The mean healing time was 7.14 months (range, 4 to 13 months); differences in healing time between fracture locations were not statistically significant (p=0.83). The mean follow-up duration was 19.83 months (range, 12 to 30 months); there were no statistically significant differences in follow-up times in terms of fracture sites (p=0.51). The VAS score for the knee was 0 in 49 patients (84.5%) and <3 in nine patients (15.5%). The Lysholm score differences between the fracture location groups were not statistically significant (p=0.33). CONCLUSION: Suprapatellar tibial IMN can be applicable to extra-articular tibial fractures in all locations. Providing easy anatomic reduction in semiextention, convenient fluoroscopic imaging, safety for the PF joint, acceptable anterior knee pain, and satisfactory functional outcomes render SP approach more feasible.

Comparison of 2-year clinical and radiological outcomes between volar plating and external fixation with additional K-wires for AO Type C distal radius fractures.

BACKGROUND: Surgical treatment of distal intraarticular radius fractures remains controversial. Our aim was to compare the clinical and radiological outcomes between volar plating (VP) and external fixation (EF) for distal intraarticular radius fractures two years postoperatively. METHODS: This retrospective study included 59 patients with 62 intraarticular AO Type C distal radius fractures. We distinguished two groups: patients treated with internal fixation (volar locking plate, VP group: 41 fractures), and patients treated with an external fixator and K-wires (EF group: 21 fractures). The clinical assessment included range of motion, grip strength, disability of the arm, shoulder, and hand (DASH), and visual analog scale scores. Radiological measurements comprised flexion and extension, radial volar tilt, inclination, height, shortening, and ulnar variance. RESULTS: Postoperative grip strength and flexion angles were better after VP (P = 0.004, P = 0.009), but there was no difference in DASH scores (P = 0.341). Radial inclination was significantly different compared to that of the uninjured hand after VP (P = 0.0183), but not EF (P = 0.11). DISCUSSION: VP and EF result in similar clinical and radiological outcomes after 2 years. Function is not restored to the functionality of the contralateral and noninjured hand.

Vacuum-assisted closure versus moist dressings in the treatment of diabetic wound ulcers after partial foot amputation: A retrospective analysis in 65 patients.

PURPOSE: Changes in weight-bearing patterns after partial foot amputations may lead to new localized high-pressure points and keratosis due to ulcerations in patients with neuropathies and hypovascular limbs. As a result, diabetic foot ulcers (DFUs) after partial foot amputations are very complex. The aim of this study was to compare the effectiveness of vacuum-assisted closure (VAC) therapy with conventional moist wound dressings in the treatment of diabetic wound ulcers after partial foot amputations. METHODS: Sixty-five diabetic patients with a DFU, who had previously undergone partial foot amputation surgery, were assigned to treatment with VAC (group A: 31 patients) or conventional wound moist dressing (group B: 34 patients). The final results were considered as failed treatment if reamputation was required. Conversely, reaching 90% of wound granulation was considered to be a successful endpoint. RESULTS: The average time to reach 90% granulation tissue was significantly lower in group A (7.8 ± 1.2 weeks vs. 11.1 ± 1.2 weeks; p < 0.001). However, there was no significant difference regarding the reamputation requirements; 38.7% (12 patients) in group A and 41.2% (14 patients) in group B, ( p = 0.839). CONCLUSION: The results of this study allowed us to conclude that VAC therapy system appears to be an effective treatment for patients with complex DFUs who had previously undergone partial foot amputation.

A comparative study of three commonly used fixation techniques for isolated medial malleolus fracture.

OBJECTIVES: This study aims to compare the three most commonly used fixation techniques: tension-band wire fixation, partially threaded cannulated screws, and fully threaded cannulated headless compression screws. PATIENTS AND METHODS: Ninety patients with medial malleolus fractures were included in the study. Patients were divided into three groups. Group A included patients who underwent tension-band wire fixation (n=26), Group B partially threaded cannulated compression screws (n=32), and Group C fully threaded cannulated headless compression screws (n=32). The type of medial malleolus fracture, healing rates, implant-related complications, rate of infection, hardware removal, weight-bearing restrictions, mean interval time from the injury to the surgery, and Body Mass Indexes (BMIs) were investigated. The patients' radiographs (standard anteroposterior, lateral, and mortise) were reviewed. The American Orthopedic Foot and Ankle Society (AOFAS) scoring system was used for clinical evaluation. RESULTS: No significant difference was observed between the three groups in terms of age, gender, BMI, follow-up period, and fracture type. Union rate for group C was significantly shorter than groups A and B. There was no implant failure or irritation in group C and this was statistically significant comparing to group A and B (p=0.037). However, there was no significant difference between group A and B (p=0.41). There were no significant differences in the three groups according to AOFAS. Patients with low BMI in groups A and B had a high rate of implant-related complications. There was a significant correlation between low BMI and implant-related complication (p<0.001). CONCLUSION: Union rate in the group who were operated with fully threaded cannulated headless compression screws was significantly shorter than the other groups. This study has shown that tension band wiring and partially threaded cannulated compression screws can cause irritation of soft tissues and pain over the hardware implantation site. Patients with low BMI are vulnerable for implant-related complications.

The effect of N-acetylcysteine on mechanical fatigue resistance of antibiotic-loaded bone cement.

BACKGROUND: This biomechanical study evaluates the effect of N-acetylcysteine alone and in combination with the most commonly used antibiotic-loaded bone cement mixtures. METHODS: We mixed eight bone cement mixture groups including combinations of N-acetylcysteine, gentamicin, teicoplanin, and vancomycin and applied a four-point bending test individually to each sample on days 1 and 15 using an MTS Acumen test device. RESULTS: The result was less than 50 MPa-the limit declared by the ISO (International Standards Organization)-in only the "gentamicin + bone cement + N-acetylcysteine" group. Mechanical fatigue resistance of the bone cement decreased significantly with the addition of N-acetylcysteine both on day 1 and day 15 (p <  0.001). With the addition of N-acetylcysteine into the "gentamicin + bone cement" and "vancomycin + bone cement" mixtures, a significant decrease in mechanical fatigue resistance was observed both on day 1 and day 15 (p <  0.001). In contrast, with the addition of N-acetylcysteine into the "teicoplanin + bone cement" mixture, no significant difference in mechanical fatigue resistance was observed on days 1 and 15 (p = 0.093, p = 0.356). CONCLUSION: Preliminary results indicate that adding N-acetylcysteine to teicoplanin-loaded bone cement does not significantly affect the cement's mechanical resistance, potentially leading to a new avenue for preventing and treating peri-prosthetic joint infection. N-acetylcysteine may, therefore, be considered as an alternative agent to be added to antibiotic-loaded bone cement mixtures used in the prevention of peri-prosthetic joint infection.

Evaluation of surgical outcome in advanced age patients with developmental hip dysplasia.

BACKGROUND: This study aimed at determining the efficacy of the surgical treatment conducted on children with delayed presentation developmental dysplasia of the hip (DDH). The objective was to provide a good comparison of functional and radiographic outcomes and to determine various surgical treatment options. METHOD: In this study, we evaluated the results of 38 hips of 27 patients aged 4 years onset which had been operated due to DDH. Radiographic outcomes were evaluated by using acetabular index, CE angle, Tonnis and the Severin classification system. Clinical evaluation was made by using IOWA hip scores. Degenerative changes were evaluated according to Boyer and avascular necrosis according to Kalamchi-MacEwen criteria. RESULTS: The mean age of the patients at the operation time was 10 years 3 months (range: 4 years 3 months-30 years). While the mean acetabular index was 37.97 preoperatively, in the last follow-up it was 19.92. Thirty-six hips (94%) had an excellent and good outcomes, and two hips (%6) had a fair outcome with respect to the Severin criteria. The mean hip score with respect to IOWA was 93.736 (range: 75-98) and the rate of excellent and good outcomes was 98%. CONCLUSION: For the treatment of patients with DDH of late onset, a one-staged operative procedure is recommended. This method is applied successfully and enables us to achieve good clinical and radiographic results.

Displaced acromion fracture: A rare injury, case report.

INTRODUCTION: Acromion fractures are extremely rare. There are no common accepted treatment schemes and fixation methods We aimed to present a case which may contribute to the diagnosis and treatment of acromion fracture in a patient with polytrauma. PRESENTATION OF CASE: Acromion fracture associated with scapula and clavicle fractures was diagnosed in 40 years old patient and treated with open reduction and cannulated screw fixation. The fracture healing was completed without causing subacromial impingement. DISCUSSION: In patients with polytrauma, diagnosis and treatment of acromion fractures can be delayed or overlooked. In improperly treated acromion fractures; pain, movement restriction, subacromial impingement, rotator cuff injury and symptomatic nonunion can occur. CONCLUSION: We recommend early surgical treatment for displaced acromion fractures, reduction of subacromial space and disruption of the superior shoulder suspensory complex.

Lunatum excision and scaphocapitate arthrodesis in Kienböck's disease.

PURPOSE: The aim of this study was to compare functional results before and after lunatum excision and scaphocapitate arthrodesis (SCA) using an angular stable circular plate in patients with Lichtman's stage IIIB Kienböck's disease. METHODS: The study included nine patients (six females and three males) with a mean age of 33.2 ± 11 years (range: 18-54 years). Clinical and radiological assessment before and after surgery included wrist extension and flexion, range of motion and grip strength, visual analogue scale (VAS) score to assess pain, modified Mayo wrist scores, and measurements of the scapholunate (SL) angle and modified carpal height ratio. RESULTS: The mean follow-up period was 17.33 ± 4.69 months (range: 12-24 months), mean operation time was 56.67 ± 12.5 min (range: 45-75 min) and mean hospitalization time was 3.44 ± 1.13 days (range: 2-6 days). Preoperative mean wrist extension was 23.89° ± 4.17°, mean wrist flexion was 32.22° ± 5.07°, mean grip strength compared to the healthy side was 34% (range: 28-37%) and mean VAS score was 7.6 (range: 7-8). Modified Mayo wrist scores were poor in all of the nine patients. Post-operative mean wrist extension was 27.78° ± 4.41°, mean wrist flexion was 40.56° ± 4.64°, mean grip strength compared to the healthy side was 71% (range: 63-81%) and mean VAS score was recorded as 1.4 (range: 1-2). Modified Mayo wrist scores were good in five and moderate in four patients. No patients had non-union or additional surgery. CONCLUSION: Lunatum excision and SCA using angular stable circular plate fixation provide pain relief with acceptable preservation of the range of motion.

Percutaneous cannulated screw fixation for pediatric epiphyseal ankle fractures.

BACKGROUND: Ankle injuries are among the most common injuries in children. The aim of this study was to compare the efficacies of two percutaneous fixation methods after closed reduction in physeal ankle fractures. METHODS: We reviewed the cases of 24 patients with a mean age of 12.29 years; 16 were male, and 8 were female. Only patients with fractures of Salter-Harris types 2, 3, and 4 with displacements greater than 2 mm were included in the study. Patients were treated with closed reduction manipulation and percutaneous screw fixation. For each patient, either cannulated or headless full threaded compressive screws were used for percutaneous fixation. Radiological and clinical healing time, range of motion (ROM), American Orthopaedic Foot and Ankle Society (AOFAS) score and physeal arrest were then measured. RESULTS: The mean follow-up time was 13 months. The mean time until cast removal was 3.5 weeks (range 2-5). A full ROM was achieved at an average of 5.7 weeks postoperatively (range 4-8). The radiologic healing time was 6.1 weeks (range 4-7). The patients' clinical healing time averaged 6.8 weeks (range 5-8). Differences in radiologic healing time (p = 0.487), clinical healing time (p = 0.192), AOFAS score (p = 0.467), and complication rate (p = 0.519) between patients who received the headless compressive screw and those who received the cannulated screw for fixation were not statistically significant. CONCLUSIONS: We demonstrate good clinical results with closed reduction and the percutaneous screw fixation method. Both cannulated and headless compressive screws can be used safely as a treatment method in physeal ankle fractures.

An unusual cause of mass localized on vastus lateralis muscle in childhood: Hydatid cyst.

INTRODUCTION: Musculoskeletal hydatid disease is a rare pathology and its diagnosis is often delayed because of slowly growing mass without inflammation. It is critical to suspicious clinical diagnosis in rural endemic areas and for preoperative diagnosis of this disease. PRESENTATION OF CASE: We present a 9-year-old boy referred with mass located on the anterolateral part of distal thigh. Diagnosis was verified with MRI histopathologically for the presence of hydatid cyst located in vastus lateralis muscle. Magnetic resonance imaging (MRI) was performed for further imaging. MRI showed an oval cystic mass approximately 77×20×18mm in the left vastus lateralis muscle, containing round-shaped daughter cysts. Patients were treated with surgical excision and medical therapy. Clinical, radiological and serologic tests showed no recurrence after treatment. DISCUSSION: The muscle is considered an unfavorable site for hydatidosis because of its high lactic acid level that creates an unfavorable milieu for growth. The detachment of the germinative membrane from pericyst (water-lily sign) is considered to be pathognomonic and is reported in locations other than the liver and lung in magnetic resonance imaging. Surgery is the most effective way to treat hydatid cysts. Complete surgical resection and medical therapy are the preferred treatment for isolated echinococcosis. CONCLUSION: Hydatid cyst in vastus lateralis is a very rare disease. Hydatid cyst should be kept in mind when observing soft tissue mass of the extremities in patients from areas endemic of Echinococcus granulosus.

[The results of low profile locking anatomical plate application for the treatment of Edinburg type 2 clavicle diaphysis fractures]. / Klavikula Edinburg tip 2 cisim kiriklarinin cerrahi tedavisinde düsük profilli anatomik kilitli plak uygulamasi sonuçlari.

BACKGROUND: Although conservative measures are the general choice of treatment for clavicle fractures; surgery is advised for displaced and multifragmentary fractures. Open reduction and osteosynthesis with a plate-screw combination are used widely as surgical treatment options. METHODS: In our study, there were 21 patients with Edinburgh Type IIB clavicle middiaphysal fractures treated surgically with locked anatomical clavicle plate. RESULTS: Among those 31 patients and 32 clavicle middiaphysal fractures, Seventeen clavicle fractures were right-side, and fifteen were left side. 24 of them were males, 7 of them were females and the mean age was 28 (15-62) years. The mean follow-up period was 12.3 (6-36) months and healing time 15.2 (12-20) weeks. 3 patients with Type IIB fracture had a healing time longer than 12 weeks. As the result of healing patients', mean constant score was 92 (85-98) and DASH score 9 (2-20). There has been a problem due to the implant detected in 3 (9%) patients. DISCUSSION: Successful functional and radiographic results can be achieved as a result of the surgical treatment of the clavicle middiaphysal fractures with locked anatomical plates.

[The results of autologous bone graft and titanium headless cannulated compression screw for treatment of scaphoid nonunion]. / Skafoid psödoartroz tedavisinde otolog kemik grefti ve titanyum bassiz kanüllü kompresyon vidasi kombinasyonu uygulama sonuçlari.

BACKGROUND: We aimed to present the clinical and radiological results of patients treated with debridement, iliac bone graft and titanium headless compression screw for scaphoid nonunion. METHODS: We retrospectively evaluated 24 patients (23 males, 1 female) who underwent this technique between 2009 and 2012, with a minimum of 12 months' follow-up. Nonunion was determined as no union evidence within eight weeks on radiological view. Scaphoid fracture was classified according to Herbert classification and anatomical location. Functional evaluation was performed using the Mayo wrist scoring system. RESULTS: According to the Herbert classification system, there were 20 D1 and 4 D2 fractures. Anatomical location included 1 distal, 6 proximal and 17 corpus. Fracture union was achieved in all but 2 patients, with a mean union time of 9.5 weeks (6-15). Scapholunate angle and radiolunate angle were measured as a mean 32° (39°-50°) and 7° (4°-10°) at the latest follow-up radiographic examination. There was a statistically significant correlation between the length of the pseudoarthrosis period and union time (p=0.003). Union time of proximal fractures was longer than of the others (p=0.004). Mayo wrist score was 86 (80-95). DISCUSSION: Autologous iliac bone graft and titanium headless cannulated compression screw combination via volar approach is safe and effective for scaphoid nonunion.

An unusual cause of recurrent joint effusions: nonhemophilic hemosiderotic synovitis of the knee.

A 20-year-old female presented with a painful swelling in the right knee and snapping sensation on joint motion that appeared without trauma and recurred several times. She had no history of a bleeding disease or trauma. Physical examination showed no signs of rash or temperature change or systemic or local findings of an infection. The knee was tender and knee motion was painful, with 90 degrees of flexion and full extension. The ballottement test was positive. All laboratory tests including rheumatologic and bleeding parameters were normal. Joint effusion analysis was normal except for its rusty-brown color. Magnetic resonance imaging showed synovial hypertrophy and grade 2 degeneration in the medial meniscus. During diagnostic and surgical arthroscopy, rust-colored synovial hypertrophy was noted in the suprapatellar pouch accompanied by patchy villi and nodules and cystic changes. The gross appearance of the synovium mimicked that of pigmented villonodular synovitis. Biopsy specimens were obtained from different parts of the synovium and a subtotal synovectomy was performed. The histopathologic diagnosis was reported as hemosiderotic synovitis. During a three-year follow-up, she had no pain, snapping sensation, or limitation of motion. There were no recurrent effusions.

[Bucket-handle tear of a discoid lateral meniscus in a 6-year-old girl]. / Alti yasindaki kiz hastada diskoid lateral menisküsün kova sapi yirtigi.

A six-year-old girl was examined upon development of pain, swelling, and locking in her right knee after a considerable period of discomfort and popping sensation. She had no history of trauma. Magnetic resonance imaging showed a discoid lateral meniscus, filling the entire lateral plateau and exhibiting signs of degeneration. On arthroscopic examination, a bucket-handle tear of the discoid lateral meniscus was noted and the patient was treated with arthroscopic subtotal meniscectomy. During the first month of follow-up, the patient had a full range of motion and normal gait. At three years, she maintained full range of motion without pain, locking, or popping. Due to the likelihood of joint degeneration, long-term follow-up was recommended.