Tibial cancellous bone auto-grafting for medial open-wedge high tibial osteotomy: bone void filling with tissue harvested from osteotomized medullary canal.

The aim of the study was to evaluate the clinical and radiological outcomes in a series of patients undergoing open wedge high tibial osteotomy (OWHTO) using tibial cancellous autograft harvested from the osteotomized medullary canal which is not reported in the literature before. Patients with medial compartment osteoarthritis were treated with OWHTO and tibial cancellous auto- grafting performed from the osteotomized medullary canal and used for bone void filling. Seventy patients (seventy-two knees) treated with OWHTO were analyzed. All patients started partial weight-bearing with crutches the day after surgery and full-weight bearing eight weeks after surgery, according to radiological evaluation. Fifty-seven women and 13 men with a mean age of 54.2±8.1 years were evaluated in this study. The mean correction angle was 8.4±2.5° (range: 5.3°-14.3°). The osteotomy sites of all patients were grafted with tibial cancellous autografts. In all patients bony union was detected after surgery. No implant failures or major complications were en- countered. Clinical and radiological findings revealed that bone void filling with the harvested autograft from the osteotomized medullary canal may be a satisfactory and reliable option in OWHTO.

Use of Tibial Cortical Autograft for the Osteotomy Site in Medial Opening-Wedge High Tibial Osteotomy.

Background: Medial opening-wedge high tibial osteotomy (OWHTO) is a useful treatment option in patients with medial compartment osteoarthritis. Typically, the osteotomy site is filled with material such as autologous bone graft, allograft, or synthetic bone substitute. However, all these options have disadvantages. Purpose/Hypothesis: The purpose of this study was to describe tibial cortical autograft as an alternative to conventional graft options. It was hypothesized that the tibial rectangular cortical bone that is removed from the proximal medial cortical surface of the distal tibial fragment longitudinally could be a reliable option for recovery of the gap in the osteotomy area. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 520 patients with medial compartment osteoarthritis who underwent OWHTO between June 2009 and March 2019 were retrospectively analyzed. Patients were divided into 3 groups according to the graft material used to fill the osteotomy site: allograft in group A, iliac crest autograft in group B, and tibial autograft in group C. Bone union, evaluated by radiographs performed at 2 weeks, 4 weeks, 2 months, 3 months, 6 months, and 1 year postoperatively, was defined as occurring when at least 50% of the gap site was bridged with callus. Clinical assessment was performed using the International Knee Documentation Committee (IKDC) and Lysholm scores. Results: Included were 122 patients: 40 patients in group A, 42 patients in group B, and 40 patients in group C. The mean correction was 13.87°± 3.58° in group A, 12.33°± 3.92° in group B, and 14.10°± 2.99° in group C. The mean time for radiological bone union was 6.95 ± 1.40 months in group A, 4.48 ± 1.02 months in group B, and 5.07 ± 1.70 months in group C. Patients in all groups had similar IKDC and Lysholm scores at the final follow-up. Conclusion: This is the first report of this specific procedure in the literature. All clinical and radiological findings showed that use of tibial cortical autograft was an efficient method in patients undergoing OWHTO.

A minimally invasive technique for the reduction of calcaneal fractures using the Endobutton®.

Calcaneal fractures are very common injuries, and closed reduction-percutaneous pinning, open reduction-internal fixation, and primary arthrodesis are the procedures used in the surgical treatment of these injuries. The aim of surgical treatment is to restore the normal biomechanics of the Achilles tendon and rearfoot by anatomic reduction of the articular surfaces. Minimization of the soft tissue complications commonly associated with the open treatment of calcaneal fractures can be achieved using indirect closed reduction and Kirschner wire or screw-assisted minimally invasive percutaneous osteosynthesis methods. In the present report, we describe a technique for the treatment of calcaneal fractures associated with soft tissues that are at risk of complications and present the cases of 3 patients treated with indirect, minimally invasive reduction of comminuted calcaneal fractures with the Endobutton(®) fixation device. From our experience with this method, we believe it will be useful in cases of acute calcaneal fracture with pronounced soft tissue injury localized to the hindfoot.

Treatment for painful bone marrow edema by open wedge tibial osteotomy.

We evaluated the results of patients who had undergone medial open wedge proximal tibial osteotomy, with painful bone marrow edema in the medial tibial plateau. The study included 21 patients who had presented with knee pain and whose MRIs showed bone marrow edema in medial plateau. The degree of osteoarthritis was evaluated radiologically according to the Kellgren-Lawrence criteria; 6 cases were Grade 1, 11 cases were Grade 2, and 3 cases were Grade 3. Preoperative varus angle was a mean of 2.19° (0-4). The bone marrow edema was classified according to the width of the lesions extending into the joint surface subchondral area on MRI T2 sequences. Open wedge osteotomy was performed in all patients. The postoperative results were evaluated by X-ray, MRI, and WOMAC (Western Ontario and McMaster Universities) knee scores. The preoperative 2.19° varus angle was evaluated postoperatively as valgus 6.57° (4-8°) (p < 0.05). The postoperative WOMAC knee scores revealed a significant decrease in pain (p < 0.05). In conclusion, we are of the opinion that medial open wedge proximal tibial osteotomy is an effective treatment in patients who have painful bone marrow edema in medial tibia plateau.

Humeral fractures sustained during arm wrestling.

PURPOSE: The aim of this study was to present our experience of treating humerus fracture sustained during arm wrestling. METHODS: Data of patients treated in our clinic with the diagnosis of humeral shaft fracture due to arm wrestling between 2000 and 2020 was retrospectively reviewed. Data collected included age, sex, dominant arm, history of professional or experienced participation, type and laterality of fracture, presence of radial nerve palsy, other surgical complications, management (surgical or conservative), duration of union defined as the time from injury until callus was evident on the radiograph, and the range of motion of the elbow joint at the last follow-up. RESULTS: Nineteen patients with humeral shaft fracture as a result of the arm wrestling were included. All had right arm fracture and all had right as the dominant side. All of the fractures were spiral at the distal third of the humerus and medial butterfly fragment was present in eleven (57.9%). Seven (36.8%) were treated surgically. Five (26.3%) had radial nerve palsy on admission. At last follow-up, no patient had neural deficit and none had significant loss of range of movement. CONCLUSION: Arm wrestling is an important cause of humerus shaft fracture. The dominant side is invariably affected. In this series all fractures were spiral type and occurred in the distal third of the humerus. One quarter of patients experienced radial nerve palsy, which can resolve spontaneously. Satisfactory results can be obtained with both conservative and surgical treatment. LEVEL OF EVIDENCE: IV.

Distraction osteogenesis is inhibited by cancer radiotherapy with Co 60.

AIM: To investigate the effects of radiotherapy on distraction osteogenesis performed on the same bone in an area that has not received radiation. Radiotherapy (Co60) was carried out in a region where tumors may develop, and then, on the assumption that the tumoral region had been removed, distraction osteogenesis was carried out, and the effects were investigated. METHOD: Thirty New Zealand rabbits were randomized into two groups, a study group (15 rabbits) and a control group (15 rabbits). In the study group, Co60 was administered by teletherapy to the distal half of the left tibia. Rabbits in the control group were kept in the same environment for the same period, but were not subjected to radiotherapy. Four weeks after radiotherapy, osteotomy was performed on the proximal part of the left tibia of all subjects, and distraction was carried out until 10mm. After distraction was completed, the outcomes were evaluated radiologically, scintigraphically, and histopathologically, and the results were compared. RESULTS: New bone formation achieved through distraction osteogenesis in the study group animals was inadequate, while new bone tissue achieved in the control group was superior (P < 0.001). CONCLUSION: Radiotherapy has a negative effect on distraction osteogenesis, even if performed on a different part of the bone.

The role of melatonin as a link between head injury and enhanced osteogenesis.

We hypothesize that in the case of an individual with a head injury, melatonin can enhance osteogenesis. In virtually all species to date whether nocturnal or diurnal, melatonin is synthesized and secreted during the dark phase of the day. In traumatic subarachnoid hemorrhages, in the hypothalamic syndrome, the melatonin content was very high in liquor. This was determined by a fluorimetric method, especially modified for this purpose. Osteoblastic activity rises with the increase of melatonin. Healing of a fracture of long or large bone can often be accelerated in patients with severe traumatic brain injury. However, a melatonin which could perhaps induce enhanced osteogenesis has not yet been identified. Melatonin might cause early bone healing and hypertrophic callus.

Treatment of Femur Fractures in Preschool Children with Double Pin Technique: Immediate Incorporated Hip Spica Casting by Two K-Wires.

The immediate hip spica casting is a popular treatment method for femoral fractures in the pediatric age group. Femoral shortening is the unacceptable result for the treatment. In this technique, we tried to describe the immediate spica casting technique pinning with double K-wire in preschool children and evaluate the results with this method. Sixteen patients (ten boys and six girls) are treated with this technique. Patients were treated under general anesthesia in the operating room. K-wire was introduced in the supracondylar area of the femur passing from the lateral to the medial side through both cortexes, and removed from the skin in the medial section. A second K-wire was introduced through the lateral side of the proximal fragment. While an assistant was applying traction to the pin to maintain the reduction, the lower extremity was put in a spica cast on the fractured side, while the knee joint on the other side was excluded from the spica casting process. The angulation after hip spica cast applied was 9.1° (range 7°-12°) on the frontal plane and 8.9° (range 5°-17°) on the sagittal plane. After spica cast removal, it was 8.5° (range 5°-13°) on the frontal plane and 9° (range 5°-17°) on the sagittal plane. No significant difference was found. The final mean leg length discrepancy was 4.8 mm (range 0-10 mm) at the time of cast removal. This technique may be effective for femoral diaphyseal fractures in preschool children to combine the spirits of external fixation with hip spica casting in one construct in order to correct angular deformities and length discrepancies.

Treatment of calcaneal fractures with closed reduction and the Endobutton-assisted technique: short-term analysis.

BACKGROUND: Closed reduction and percutaneous pinning, open reduction and internal fixation, and primary arthrodesis are procedures used in the surgical treatment of calcaneal fractures. This study presents short-term clinical and radiologic results of patients with calcaneal fractures treated by closed indirect reduction with Endobutton-assisted minimally invasive osteosynthesis. METHODS: Twenty-one feet of 18 patients (four women and 14 men) with calcaneal fractures were retrospectively analyzed. Böhler and Gissane angles were measured from the preoperative, postoperative, and latest follow-up lateral radiographs of the feet. American Orthopaedic Foot and Ankle Society (AOFAS) scores were used for the 6-month and latest follow-up clinical assessments. RESULTS: The mean preoperative Böhler angle of 17.1° was corrected to a mean of 20.4° postoperatively. The mean value of this angle measured at the time of latest follow-up was 21.3°. The mean preoperative and postoperative Gissane angles were 116° and 117.8°, respectively. The mean value of this angle measured at the time of latest follow-up was 117.4°. The mean 6-month postoperative AOFAS score was 59.8 points. The mean AOFAS score at the time of latest follow-up (79.1 points) was significantly higher than the mean score 6 months postoperatively (P < .001). Regarding the latest follow-up AOFAS scores, four were poor, four were moderate, ten were good, and three were excellent. CONCLUSIONS: With a low learning curve and satisfactory clinical outcomes, this technique can be used in acute, edematous cases with soft-tissue injuries to avoid calcaneal enlargement, infection, and soft-tissue problems.

The effects of electromagnetic field on distraction osteogenesis.

The effects of electromagnetic field on distraction osteogenesis and new bony tissue were investigated. Twenty-five New Zealand rabbits were divided into an experimental (12 rabbits) and a control (13 rabbits) group. An osteotomy was performed on the right tibia in the diaphyseal region in both groups. The experimental group was exposed to a magnetic field of 50 Hz 1.0 mT for 3 hours a day for 13 weeks. The control group was kept in a similar environment but with no electromagnetic field. The distraction was continued until an increase of 10 mm was achieved. At weeks 4, 8, and 13, radiography, scintigraphy, and a biopsy were performed in both groups, and the results were statistically analyzed. The X-ray results were similar in both groups at all times. On the other hand while the scintigraphic and histopathological results were similar at weeks 4 and 13 in both groups, the osteoblastic activity was significantly greater in the experimental group at week 8 (p < 0.01). In conclusion an electromagnetic field increases the osteoblastic activity and osteogenesis, but has little effect during the remodeling phase.

[Comparison between the results of intramedullary nailing and compression plate fixation in the treatment of humerus fractures]. / Humerus kirikli olgularda kilitli intramedüller çivi ve plak ile tedavi sonuçlarinin karsilastirilmasi.

OBJECTIVES: The results of open reduction and internal fixation of humeral shaft fractures by either an intramedullary nail or a dynamic compression plate were compared. METHODS: The study included 60 patients (43 males, 17 females; mean age 38 years; range 19 to 61 years) with humerus fractures. Thirty-three patients were treated with intramedullary nails and 27 patients with dynamic compression plates. Functional results were evaluated according to the Stewart and Hundley's criteria. The two methods were compared. The mean follow-up period was 42 months (range 28 to 72 months). RESULTS: Healing times did not differ between the two treatment groups (p>0.05). Radial nerve palsy occurred only in the dynamic compression plate group, with four patients being affected. On the other hand, the rate of non-union was significantly higher in patients treated with intramedullary nailing (p<0.05). CONCLUSION: No ideal fixation technique exists in the treatment of humerus fractures. Despite higher non-union rates, intramedullary nailing may be the method of choice in the treatment of humerus fractures because of such advantages as low morbidity, small dissection of soft tissues, and greater ease of application.

[The floating knee in adults: twenty-four cases of ipsilateral fractures of the femur and the tibia]. / Yirmi dört olguda ipsilateral femur ve tibia kirigi: Eriskinlerde "floating knee"

OBJECTIVES: We evaluated the presenting features of ipsilateral femoral and tibial fractures in adults, and the effects of both fracture type and severity of skeletal injury on the results. METHODS: The study included 24 patients (22 men, 2 women; mean age 38 years; range 17 to 75 years). According to the classification by Letts et al., the types of the fractures were as follows: type A (7), type B (2), type C (5), type D (7), and type E (3). Femur fractures were treated by locked intramedullary nails, AO plates, plate-screws, unilateral external fixator, or dynamic condylar screws, and tibia fractures by external fixator, plate-screws, locked intramedullary nailing, or with conservative methods. Amputation at the fracture level was required in a patient with type 3C open tibia fracture. The mean follow-up was 3.2 years (range 1.3 to 7 years). RESULTS: According to the criteria by Kalström and Olerud, the results were excellent in three patients, good in nine patients, fair in five patients, and poor in six patients. The mean skeletal injury scores were 4.4 and 3 in patients having fair and poor results and in those with good and excellent results, respectively. Fair and poor results corresponded to type A (1 patient), type C, type D, or type E fractures. Five patients with type 3 open fractures had fair or poor results. Thirteen patients (54%) had at least one complication. CONCLUSION: Patients with type C, D, or E fractures and those with greater skeletal injury scores are more likely to have fair or poor results due to the open nature of the fracture and to increased involvement of the knee joint. Although there is not an ideal method, rigid internal fixation seems to be more appropriate in fractures other than type 3 open tibia fractures.

A comparison of intramedullary nailing and plate-screw fixation in the treatment for ipsilateral fracture of the hip and femoral shaft.

We compared the outcomes of intramedullary nailing with plate-screw fixation in the treatment for ipsilateral fracture of the hip and femoral shaft. A retrospective study. Level 1 Trauma. Forty-one patients (32 males and 9 females; mean age, 34 years; age range, 21-53) with ipsilateral hip and femoral shaft fractures were treated between 1995 and 2005. Eighteen patients were injured in motor vehicle accidents, and 23 fell from a height. All patients were treated by one of the two methods of internal fixation: a screw-plate fixation (n = 24, Group I) or intramedullary nailing (n = 17, Group II). The fracture union time, nonunion, delayed union, implant failure, need of further surgeries, and functional outcomes were investigated and compared. Fisher's exact test showed that Group I had a significantly higher frequency of nonunion than that of Group II (P = 0.029). Although Group I had more nonunions, delayed unions, and revision operations than Group II, the total union time was similar for both groups. Intramedullary nailing was found to be superior to screw-plate fixation due to improved functional bearing, increased rate of union, stability, and mechanical solidity. The reconstruction nail method is an acceptable alternative treatment for ipsilateral hip and femoral shaft fractures.

Isolated avulsion fracture of lesser tuberosity of the humerus: Review of the literature and report of two cases.

Two cases of acute isolated avulsion fracture of the lesser tuberosity of the humerus and their short-term outcome are presented with a review of previously reported cases. Open reduction and internal fixation was performed. Outcomes were excellent, and the patients regained their normal pain-free shoulder function 3 months after the operation. This was a Level IV study.

Revision of the Gunston polycentric knee arthroplasty with total knee arthroplasty.

The Gunston polycentric knee arthroplasty, first designed and performed by Frank Gunston in 1971, is the first prosthesis considering the natural knee biomechanics. Although the polycentric knee arthroplasty showed encouraging results to relieve pain and to preserve the preoperative range of motion and joint instability, the improvements in prosthesis design and arthroplasty technology rapidly made the polycentric knee prosthesis obsolete. Herein, we report a 58-year old male patient who had revision of the Gunston polycentric knee arthroplasty with total knee arthroplasty performed 32 years after the initial operation.

Is external fixation in pediatric femoral fractures a risk factor for refracture?

The aim of this study was to investigate whether external fixation is a risk factor for refracture by comparing the outcomes of children who received three different forms of treatment of femoral fractures. One hundred ninety-two patients treated for femoral fracture between 1990 and 1999 who underwent final examination were assessed. One hundred were treated with hip spica casting after traction, 57 with closed reduction and external fixation, and 35 with open reduction and external fixation. Morbidity results such as time to union, length of hospital stay, refracture, and wire site infection were statistically evaluated. Patients undergoing open reduction had a greater time to union and length of hospital stay and a higher refracture rate. The difference was statistically significant. Wire site infection occurred in all three groups; there was no statistically significant difference between groups. The authors concluded that external fixation is not a risk factor for refracture in the treatment of pediatric closed femoral diaphyseal fractures, and that it may be used with ease in clinics with shortages of personnel and space.

Anthropometric study of patients treated for clubfoot.

The anthropometric characteristics of patients treated for clubfoot were used to investigate whether the dimensions of the foot were affected by the method of treatment. A total of 68 patients followed up for an average of 9 years were divided into three groups: group 1, conservatively treated; group 2, surgically treated; group 3, conservatively treated on one side and surgically treated on the other. The following average discrepancies in foot length were obtained: group 1, 0.91 cm; group 2, 1.5 cm; group 3, 1.09 cm. Toe lengths were shorter to the same extent as the other dimensions of the foot. These discrepancies were statistically significant. The following average discrepancies in foot width were obtained: group 1, 0.05 cm; group 2, 0.37 cm; group 3, 0.054 cm; these were insignificant. The authors believe that the degree of discrepancy may depend not solely on the method, but on the severity of the deformity as well.