Biomechanical comparison of fixation methods on third-generation femoral composite bone models in Pauwels type 3 femoral neck fractures: Contribution of the medial buttress plate to fixation.

OBJECTIVE: To compare the use of cannulated screws in an inverted triangular configuration, medial buttress plates, and the combination of these 2 fixation methods in the treatment of Pauwels type 3 femoral neck fractures. METHODS: Twenty-eight anatomical composite third-generation femoral bone models were divided into 4 groups. The control group (group 1) was formed with 7 third-generation intact bone models. The fracture model was created with a 70° cutting block to fit 21 Pauwels type 3 fracture configurations. Seven models were fixed with an isolated 3.5 mm one-third semi-tubular medial buttress plate (group 2), 7 were fixed in an inverted triangular configuration with 6.5 mm cannulated screws (group 3), and 7 were fixed using a combination of 6.5 mm cannulated screws and a medial buttress plate (group 4). Cyclic loading was applied using axial forces ranging from 60 N to 600 N and moments ranging from 0.7 Nm to 7.0 Nm for 500 cycles. Once the cyclic loading stage was completed, the loads were removed from the system, and the quasi-static loading stage was employed to determine the stiffness and failure forces of the system under both axial and torsional forces. Quasi-static tests were performed with an axial speed of 1.8 mm/min and a torsional speed of 4.5°/min. The biomechanical properties of all groups were examined in terms of axial stiffness, torsional stiffness, and maximum axial force parameters. RESULTS: The stiffness values of groups 1, 2, 3, and 4 were 303 ± 35.8 N/mm, 159.6 ± 25 N/mm, 232 ± 35.9 N/mm, and 366.9 ± 58 N/mm, respectively, under axial forces (P < .01); 2172.7 ± 252.1 Nmm/°, 1225.3 ± 238.6 Nmm/°, 2123 ± 359.4 Nmm/°, and 2721.85 ± 304 Nmm/°, respectively, under torsional moments (P < .01); and 2072.1 ± 256.1 N, 1379.9 ± 290.6 N, 2099.1 ± 454.2 N, and 2648.4 ± 364.6 N, respectively, under the maximum force (P < .01). CONCLUSION: This study showed that in the fixation of Pauwels type 3 fractures formed on third-generation bone models, the utilization of half-thread cannulated screws in an inverted triangle configuration, along with a medial buttress plate, provided stronger fixation compared to the remaining implant groups and the control group. According to the evaluation of the parameters, the isolated application of a medial buttress plate had poorer biomechanical properties than other fixation methods.

Effect of transported segment size on the new bone formation of the rabbit femur in the Ilizarov bone transport method.

OBJECTIVE: This study aimed to compare histological and radiological union in the bone transport of 3 segments of different sizes to reconstruct the rabbit femur's bone defects. METHODS: Thirty rabbits were divided into 3 groups; a 1-cm defect was created in the femur in all rabbits. The length of the segment to be transferred was 10% of the femur length in group 1, 15% in group 2, and 20% in group 3. All defects were reconstructed by applying bone transport. At the end of the consolidation period, the distraction zone was compared radiologically and histologically. RESULTS: While there was no radiological difference between the groups, the highest histological scores were obtained from group 3. Osteocalcin staining revealed similar involvement in groups 2 and 3, butless involvement in group 1. CONCLUSION: Evidence from this study has shown that as the size of the segment used for bone transport increases, more stable fixation and better histological union tissue can be obtained in the rabbit femoral defect model.

The effect of preexisting radiographic hip osteoarthritis on the functional recovery after surgical treatment of intertrochanteric fractures in elderly patients.

OBJECTIVE: The aim of this study was to evaluate the effect of the grade of preexisting radiographic hip osteoarthritis on the functional outcome of elderly patients with intertrochanteric fractures treated by intramedullary fixation. METHODS: We retrospectively examined the impact of the grade of preexisting osteoarthritis on the functional outcome of 88 patients older than 60 years with intertrochanteric fractures treated by intramedullary fixation. The patients were divided into 2 groups accord ing to the grade of osteoarthritis: group 1, including 52 patients (32 females and 20 males) with Kellgren-Lawrence grades 1 and 2, and group 2, including 36 patients (24 females and 12 males) with Kellgren-Lawrence grades 3 and 4. Functional outcomes were evaluated using the Harris hip score, visual analog scale, EuroQoL general health questionnaire, and the Barthel index. RESULTS: The mean age was 74.8 ± 5.5 (range=63-87) years in group 1 and 75.06 ± 5.3 (range=64-87) years in group 2. At the last follow-up, the mean Harris hip score was significantly higher in group 1 (71.3 ± 4.3) than that of group 2 (69.5 ± 3.5) (P=.047). There was no signifi cant difference between the groups in terms of the visual analog scale (P=.102), EuroQoL general health questionnaire (P=.144), and the Barthel index (P=.261) scores. The EuroQoL general health questionnaire and Barthel index scores were worse with increasing age. CONCLUSION: As the grade of hip osteoarthritis increases, it may adversely affect the specific hip score, but this parameter alone may not be a poor prognostic factor that affects the quality of life and daily activity level. LEVEL OF EVIDENCE: Level III, Prognostic Study.

An effective nonabsorbable suture technique for distal clavicle fractures.

OBJECTIVES: The purpose of this study was to evaluate the clinical and radiologic outcomes of unstable distal clavicle fractures in patients who underwent indirect fracture fixation by performing augmentation with nonabsorbable sutures. PATIENTS AND METHODS: In this descriptive observational study, 16 patients (11 males, 5 females; mean age: 34.8±12.1 years; range, 18 to 67 years) who underwent indirect fracture fixation using nonabsorbable sutures for Neer type IIB distal clavicle fractures between January 2014 and September 2019 were retrospectively reviewed. Clinical outcomes were evaluated using the Constant-Murley score and Visual Analog Scale. RESULTS: Complete union was achieved in all patients, and mean union time was 45.3± 8.4 (range, 30 to 68) days. There were no patients with loss of reduction, infection, or requirement for additional surgery. CONCLUSION: The coracoclavicular fixation method, which was applied using nonabsorbent sutures in a limited number of Neer type IIB clavicle fractures, provides a suitable and stable fixation comparable to classical techniques.

A NEW ANATOMICAL PLATE FOR EXTRA-ARTICULAR DISTAL HUMERAL FRACTURES: BIOMECHANICAL STUDY.

Introduction: We compared the mechanical properties of two fixation techniques for the treatment of extra-articular distal third humeral fractures. Materials and Methods: Two groups were created from twenty-four humeri. Group 1 was instrumented using a new, precontoured, 8-hole (3.5-mm-diameter) locking compression plate (LCP) placed anterolaterally. Group 2 was instrumented using an 8-hole (3.5-mm-diameter) precontoured posterolateral LCP plate placed on the distal humerus. Four-point bending tests and torsion tests were performed until the specimens broke. Results: The four-point bending stiffness test showed that the stiffness of anterolaterally fixed humeri was significantly higher than that of posterolaterally fixed humeri (p<0.05). Torsion testing revealed that posterolateral fixation was associated with better yield strength (p<0.05), but the torsional stiffness did not differ significantly between the two plates (p> 0.05). Conclusions: The anterolateral plate exhibited higher bending stiffness and torsional yield strength than the posterolateral plate. Anterolateral plate fixation can thus be used to manage extra-articular distal humeral fractures. Multiaxial locking screws ensure rigid fixation, allow early elbow motion without olecranon fossa impingement, and prevent iatrogenic injury of the triceps muscle. Level of Evidence I, Therapeutic Studies Investigating the Results of Treatment.

Introdução: Comparamos as propriedades mecânicas de duas técnicas de fixação para o tratamento de fraturas extra-articulares do terço distal do úmero. Materiais e Métodos: Dois grupos foram criados a partir de vinte e quatro úmeros. O Grupo 1 foi instrumentado com uma nova placa de compressão com travamento (LCP) pré-contornada e com oito orifícios (3,5 mm de diâmetro) posicionados anterolateralmente. O Grupo 2 foi instrumentado com uma placa LCP pré-contornada posterolateral com oito orifícios (3,5 mm de diâmetro) colocada na parte distal do úmero. Testes de flexão e testes de torção a quatro pontos foram realizados até que os corpos de prova quebrassem. Resultados: O teste de rigidez à flexão de quatro pontos mostrou que a rigidez dos úmeros fixados anterolateralmente foi significativamente maior do que os úmeros fixados posterolateralmente (p <0,05). O teste de torção revelou que a fixação posterolateral foi associada a melhor força de rendimento (p <0,05), mas a rigidez à torção não diferiu significativamente entre as duas placas (p > 0,05). Conclusões: A placa anterolateral apresentou maior rigidez à flexão e resistência à tração do que a placa posterolateral. A fixação anterolateral da placa pode, portanto, ser usada para tratar fraturas extra-articulares da parte distal do úmero. Os parafusos de travamento multiaxiais garantem uma fixação rígida, permitem o movimento precoce do cotovelo sem causar impacto à fossa do olécrano e previnem lesão iatrogênica do músculo tríceps. Nível de evidência I, Estudos terapêuticos - Investigação dos resultados do tratamento.

Factors Associated with Femoral Neck Shortening After Closed or Open Reduction and Screw Fixation.

PURPOSE: This study aimed to evaluate the incidence of femoral neck shortening (FNS) after the treatment of displaced and non-displaced femoral neck fractures with closed or open reduction internal fixation, and determine the independent factors associated with this condition. METHOD: The study included 81 patients who underwent internal fixation by closed or open reduction with multiple screws between 2013 and 2018 due to femoral neck fracture (FNF) and were followed up for at least 1 year. Patients were divided into two groups as with and without FNS. The patient, fracture, and surgical parameters compared between the two groups, and the factors affecting development of FNS were investigated. RESULTS: Internal fixation was applied by closed reduction in 56 patients (69.1%) and open in 25 (30.9%). FNS was detected in 41 patients (50.6%), with the mean shortening 6.3 ± 6.4 mm. Fracture union achieved in 72 patients (89%). The mean time to fracture union was 4.3 ± 2.3 months.No statistically significant relationship found between FNS and the parameters of gender, age, smoking, reduction type, number, type and orientation of screws, Singh index, and Garden fix index (p > 0.05).However, there was significant difference between two groups regarding energy of the fracture, fragmentation, coronal angulation, Garden type, and fixation with medial buttress plate (p < 0.05). CONCLUSION: FNS is an expected condition in FNF fixed by screws. Patients with high-energy traumas and advanced Garden types are more likely to have FNS. The use of medial plate may be effective in preventing FNS.

A new anatomical plate for extra-articular distal humeral fractures: biomechanical study / Uma nova placa anatômica para fraturas extra-articulares distais do úmero: estudo biomecânico

ABSTRACT Introduction We compared the mechanical properties of two fixation techniques for the treatment of extra-articular distal third humeral fractures. Materials and Methods Two groups were created from twenty-four humeri. Group 1 was instrumented using a new, precontoured, 8-hole (3.5-mm-diameter) locking compression plate (LCP) placed anterolaterally. Group 2 was instrumented using an 8-hole (3.5-mm-diameter) precontoured posterolateral LCP plate placed on the distal humerus. Four-point bending tests and torsion tests were performed until the specimens broke. Results The four-point bending stiffness test showed that the stiffness of anterolaterally fixed humeri was significantly higher than that of posterolaterally fixed humeri (p<0.05). Torsion testing revealed that posterolateral fixation was associated with better yield strength (p<0.05), but the torsional stiffness did not differ significantly between the two plates (p> 0.05). Conclusions The anterolateral plate exhibited higher bending stiffness and torsional yield strength than the posterolateral plate. Anterolateral plate fixation can thus be used to manage extra-articular distal humeral fractures. Multiaxial locking screws ensure rigid fixation, allow early elbow motion without olecranon fossa impingement, and prevent iatrogenic injury of the triceps muscle. Level of Evidence I, Therapeutic Studies Investigating the Results of Treatment.

RESUMO Introdução Comparamos as propriedades mecânicas de duas técnicas de fixação para o tratamento de fraturas extra-articulares do terço distal do úmero. Materiais e Métodos Dois grupos foram criados a partir de vinte e quatro úmeros. O Grupo 1 foi instrumentado com uma nova placa de compressão com travamento (LCP) pré-contornada e com oito orifícios (3,5 mm de diâmetro) posicionados anterolateralmente. O Grupo 2 foi instrumentado com uma placa LCP pré-contornada posterolateral com oito orifícios (3,5 mm de diâmetro) colocada na parte distal do úmero. Testes de flexão e testes de torção a quatro pontos foram realizados até que os corpos de prova quebrassem. Resultados O teste de rigidez à flexão de quatro pontos mostrou que a rigidez dos úmeros fixados anterolateralmente foi significativamente maior do que os úmeros fixados posterolateralmente (p <0,05). O teste de torção revelou que a fixação posterolateral foi associada a melhor força de rendimento (p <0,05), mas a rigidez à torção não diferiu significativamente entre as duas placas (p > 0,05). Conclusões A placa anterolateral apresentou maior rigidez à flexão e resistência à tração do que a placa posterolateral. A fixação anterolateral da placa pode, portanto, ser usada para tratar fraturas extra-articulares da parte distal do úmero. Os parafusos de travamento multiaxiais garantem uma fixação rígida, permitem o movimento precoce do cotovelo sem causar impacto à fossa do olécrano e previnem lesão iatrogênica do músculo tríceps. Nível de evidência I, Estudos terapêuticos - Investigação dos resultados do tratamento.

The correlation between posterior cruciate ligament buckling sign and meniscofemoral ligaments: A radiological study.

OBJECTIVES: This study aims to investigate the correlation between posterior cruciate ligament (PCL) buckling phenomena and the presence or absence of the anterior meniscofemoral ligament (aMFL). PATIENTS AND METHODS: Between January 2012 and January 2019, magnetic resonance imaging of a total of knee joints of 199 patients (163 males, 16 females; mean age: 31.5±5.3 years; range, 18 to 40 years) were reviewed retrospectively. The patients were divided into four groups. The first group included 32 patients with a ruptured anterior cruciate ligament (ACL) and absent aMFL. The second group included 67 patients with a ruptured ACL and apparent aMFL. The third group included 23 patients with an intact ACL and absent aMFL, and the fourth group included 77 patients with an intact ACL and apparent aMFL. The PCL angle was used to measure the buckling degree of the ligament, as calculated as the angle between two lines drawn through the tibial and femoral central portions of the PCL insertions. We assessed the buckling phenomena of the PCL in ACL-ruptured and ACL-intact knees and examined a possible correlation between the PCL buckling angle and the presence or absence of the aMFL of Humphrey. RESULTS: In the ruptured ACL groups (Groups 1 and 2), the mean PCL buckling angle values were 133.88±6.32 and 104.83±7.34 degrees, respectively. A significant difference was detected between both groups (p=0.026). In the intact ACL groups (Groups 3 and 4), the mean PCL buckling angle values were 143.47±5.96 and 116.77±8.38 degrees, respectively. A significant difference was detected between both groups (p=0.039). No statistically significant difference was observed between Groups 1 and 3 (p=0.13) and between Groups 2 and 4 (p=0.088). CONCLUSION: The PCL buckling sign is not specific for ACL ruptures, and can be seen frequently in normal knee joints which it is strongly associated with the presence of aMFL of Humphrey.

Fixation of Posterior Malleolar Fractures with Posterior Plating Through a Posterolateral Approach.

BACKGROUND: We aimed to evaluate radiologic and clinical outcomes of ankle fractures involving posterior fragments that were fixed with a posterior plate by the posterolateral approach. METHODS: Sixty-five patients who were followed for at least 12 months and were older than 18 years were included. The posterior malleolus fractures were classified according to the Haraguchi classification system with computed tomography (CT). The posterior malleolus fragments were fixed with a plate through a posterolateral approach. Intra-articular step-off, reduction of the posterior malleolar fragment, and fibular position in the incisura were evaluated by early postoperative CT. American Orthopaedic Foot and Ankle Society (AOFAS) score and visual analog scale pain score were used for clinical assessment. RESULTS: The posterior malleolus fractures were classified as Haraguchi type 1 in 45 patients (69.2%), Haraguchi type 2 in 12 patients (18.5%), and Haraguchi type 3 in eight patients (12.3%). No patients showed signs of instability or loss of reduction on direct radiographs during follow-up. Postoperative CT showed no loss of reduction in the posterior malleolus and tibiofibular alignment. On evaluation, there was no intra-articular step-off (<1) in any of the patients. The mean AOFAS score was calculated to be 91.6. The mean visual analog scale score was 1.2. CONCLUSIONS: We conclude that direct posterior fixation with the posterolateral approach can be a good option for ankle fractures involving posterior malleolar fragments.

Cementless rectangular stems yield satisfactory results in osteoporotic bones.

BACKGROUND: The present study aims to investigate the effects sof osteoporosis on prosthesis survival by comparing the femoral stem survival rates of patients with poor and relatively good bone quality. METHODS: We retrospectively investigated 61 patients with collum femoris fractures who were treated with cementless rectangular stems between 2011 and 2015 in the Orthopaedics and Traumatology Clinic of Taksim Training and Research Hospital. The preoperative pelvic anterior-posterior radiographs of the patients were evaluated. The patients were evaluated according to the Dorr classification, and no case with a type A femur was found. The patients were divided into two groups as advanced osteoporotic type C and moderate osteoporotic type B. Thirty patients were type B according to the Dorr classification and 31 were osteoporotic type C. RESULTS: The femoral component survival was evaluated using the Engh and ARA criteria. The relationship of the ARA score with type B and type C groups was evaluated. The median ARA score was five (min 3-max 6) for both types. These two groups were also statistically compared concerning the ARA scores using the Mann-Whitney U test, which revealed no statistically significant difference (p=0.24 >0.05). The Engh values, another criterion for the survival of femoral components, were also compared. The median Engh values were 16.5 (min 9-max 24) for the Dorr type B group and 14 (min 9-max 24) for the type C group. According to the Mann-Whitney U test, there was no significant difference between the Engh values of the two groups (p=0.061 >0.05). Lastly, no statistically significant difference was found in the ARA or Engh loosening scores between the type C advanced osteoporotic group and the type B moderate osteoporotic group. CONCLUSION: Our study supports the conclusion that cementless hip arthroplasty can be applied even in advanced elderly and osteoporotic patients without additional intraoperative or postoperative risks.

Reliability of Computer-Assisted and Manual Measurement Methods for Assessment of Graf Type 1 and Type 2 Hip Sonograms.

OBJECTIVES: The purpose of this study was to investigate the interobserver, intraobserver, and intermethod reliability of computer-assisted digital and manual measurements of hip sonograms. METHODS: Seventy-four hip sonograms were evaluated in this retrospective study. Five evaluators measured digital images and manual paper printouts according to the Graf method (Arch Orthop Trauma Surg 1984; 102:248-255). Interobserver and intraobserver reliability rates were calculated. Reliability criteria were graded on a numeric scale. RESULTS: The interobserver reliability of both computer-based and manual methods for alpha angle measurements was good to excellent, but the interobserver reliability was fair to poor for beta angle measurements. Intraobserver reliability was varied. Alpha angle measurements by both manual and computer-based methods had high concordance with each other, whereas beta angle measurements had low concordance. The intermethod variability did not differ between observers. CONCLUSIONS: The alpha angle measurements had high concordance with each other for both manual and computer-based methods, whereas the beta angle measurements had low concordance. This information should be taken into account in clinical practice. Overall, the two measurement methods were reliable and consistent with each other.

Cheilectomy as a First-Line Surgical Treatment Option Yields Good Functional Results in Grade III Hallux Rigidus.

BACKGROUND: This study aimed to analyze the functional results of cheilectomy in the surgical treatment of grade III hallux rigidus and to evaluate whether cheilectomy is a preferable first-line treatment over other surgical methods. METHODS: Of 29 patients with moderate daily physical activity who underwent cheilectomy between 2009 and 2012 on being diagnosed as having grade III hallux rigidus according to the Coughlin-Shurnas grading system, 21 patients (14 women and 7 men; mean age, 59.2 years; age range, 52-67 years) (22 feet) with regular follow-up and complete medical records were included in the study. The patients were evaluated in the preoperative and postoperative periods using a visual analog scale for pain and the American Orthopaedic Foot and Ankle Society metatarsophalangeal assessment forms. RESULTS: The preoperative mean American Orthopaedic Foot and Ankle Society score of 53 (range, 29-67) improved to 78 (range, 57-92) postoperatively (Wilcoxon test P = .001). The preoperative mean visual analog scale score of 89 (range, 60-100) improved to 29 (range, 0-70) in the postoperative period (Wilcoxon test P = .001). CONCLUSIONS: As a simple and repeatable procedure that allows for further joint-sacrificing surgical procedures when required, cheilectomy is a preferable method to be applied as a first-line option for the surgical treatment of grade III hallux rigidus.