No effect of vancomycin powder to prevent infection in primary total knee arthroplasty: a retrospective review of 976 cases.

PURPOSE: Vancomycin powder (VP) has been used to prevent periprosthetic joint infection (PJI). However, studies investigating the efficacy of VP to prevent infection in primary total knee arthroplasty (TKA) are very rare. The purpose of this study was to investigate the efficacy of VP application to prevent PJI in TKA. METHODS: Between 2012 and 2016, 976 consecutive patients who underwent primary TKA were included in the present study. Patients were divided into two groups. There were 474 patients (48.6%) in the VP group and 502 patients in the control group (51.4%). Except for VP, all procedures were the same in both groups. In the VP group, 2 g of VP was poured into the joint just before the fascia was closed. Average follow-up was 53.2 months (24-84 months). RESULTS: Infection was found in 4 (0.84%) of 474 patients in the VP group and 5 (0.99%) of 502 patients in the control group. There was no statistically significant difference between groups in terms of infection rates (p = 0.535). Staphylococcus aureus was found in 2 patients in the VP group. Two patients had S. aureus and 1 patient had Pseudomonas aeruginosa in the control group. There was no statistically significant difference between groups in terms of demographic parameters (p > 0.05). CONCLUSION: Intrawound VP administration doesn't change the infection rates in primary TKA. The VP administration for preventing PJI is not recommended in primary TKA. LEVEL OF EVIDENCE: III.

Is It an Overlooked Injury? Magnetic Resonance Imaging Examination of Occult Talus Lesions Concomitant to Tibial Shaft Fracture.

Long-term studies have shown that 10% to 20% of patients continue to experience ankle pain years after tibial fracture, which causes poor functional results and dissatisfaction. The aim of this study was to show that there could be a talus injury in patients with a tibial shaft fracture and to reveal occult talus lesions with magnetic resonance imaging (MRI) examination. Fifty-two patients with a tibial shaft fracture, with closed epiphyses, not extending to the joint and with no problems in the application of MRI examination were included. All patients underwent intramedullary tibial nailing. Patients with a lesion detected on MRI were planned to be examined by MRI again at mean of 12 months later. Ankle function of the patients were evaluated with the American Orthopaedic Foot and Ankle Society, Freiburg, and Weber scoring systems at 3, 6, and 12 months postoperatively. At the first MRI, 22 (42.3%) patients with tibial shaft fracture were found to have talus lesions: 7 (13.5%) had osteochondritis dissecans, 12 (23.1%) had edema, and 3 (5.8%) had cysts. A second MRI was planned for patients with edema and osteochondritis dissecans at a mean of 12 months. Finally, at 12 months, MRI examinations revealed osteochondritis dissecans and edema in 9 (17.3%) and 8 (15.4%) patients, respectively. In the evaluations of the patients according to the ankle scoring systems, the scores of the patients with pathology determined in the talus were significantly worse statistically than those of patients with no pathology determined at 3, 6, and 12 months postoperatively. Atalus lesion accompanied the tibial shaft fracture at a rate of 37%. The talus injuries were seen especially with an indirect mechanism of trauma, in distal third fractures, in spiral fractures, and when the tibial fracture was accompanied by a lateral malleolar fracture. In the presence of findings indicating talus injury in cases of tibial shaft fracture, the talus should be evaluated with ankle MRI.

A comparative biomechanical analysis of suprapectineal and infrapectineal fixation on acetabular anterior column fracture by finite element modeling

Background/aim: The aim of this study is to compare the stability and implant stresses of suprapectineal plate with infrapectineal plate in three subconfigurations of the screw types. Materials and methods: The stabilities of different fixation methods were compared by finite element analysis on six models. Three infrapectineal and three suprapectineal models each with locked, unlocked, or combined screws were employed. Three-dimensional finite element stress analysis was performed by using isotropic materials with a load of 2.3 kN applied at standing positions. Motion at the fracture line was measured on four different points located on the pubic and iliac sides of the fracture line. Results: Infrapectineal plate fixation with unlocked screws was found to be the most stable fixation method with 0.006 mm displacement of fragments in all axes at standing positions. The suprapectineal unlocked method was found to be the most unstable in standing positions with maximum displacement values of 0.46 mm vertical shear movement in the x-axis, ­0.14 mm displacement in the y-axis, and ­0.33 mm lateral shear in the z-axis. Conclusion: The infrapectineal unlocked plate supplies the most stable fixation with the least implant stress, contrary to the suprapectineal unlocked plate, which has the lowest stability and highest implant stresses.

Intraoperative rotation control in closed intramedullary nailing in tibia diaphyseal fractures: a prospective, randomised study.

The intraoperative determination of rotation in closed intramedullar nailing of tibial fractures is difficult. In this study, a more reliable method was used and it was a more practical means of checking rotation intra-operatively for tibia diaphysis fractures. 42 patients who presented with a unilateral tibia diaphyseal fracture. were randomly divided into two groups. In Group 1, the Intraoperative Rotation Control Method (IRCM) was used and compared with Group 2 as the control group. The Delta Rotation obtained from the MRI measurements were recorded and the Mean Delta Rotation (MDR) was obtained for each group separately. Malrotation was determined at a statistically significantly lower rate in Group 1. The MDR was statistically significantly lower in Group 1. This method does not require exposure to radiation like other radiological methods. Thus, the method used can be considered to be effective in the prevention of malrotation.

Does the wedge wing in the neck screw prevent cut-out failure in Ota/AO 31-A2 trochanteric fractures in elderly patients?

The purpose of this retrospective study was to evaluate the effects of Dyna Locking Trochanteric (DLT) nail (U & I Corporation 529-1, Yonghyun-dong, Uijungbu Kyunggi-Do, Korea 480-050) in 31-A1 and 31-A2 intertrochanteric femur fractures. Eighty-seven patients (63 female and 24 male, mean age 77 years) were treated. The mean duration of followup was 16.6 +/- 3.1 months (range, 12-24 months). There were 36 cases of 31-A1 and 51 cases of 31-A2 fractures. The duration of surgery, fluoroscopy screening time, the blood loss, the hospital stay, the tip-apex distance were significantly less in the 31-A1 fracture group compared with the 31-A2 fracture group (p < 0.001). Cut-out was observed in 13 patients (14.9%) above 80 years old with 31-A2 fractures. Especially in elderly patients with unstable 31-A2 fractures, the wedge wing on the neck screw does not work properly. Therefore further biomechanical investigations and also prospective clinical studies with larger series are needed to improve the device.

The effect of rotational deformity on patellofemoral parameters following the treatment of femoral shaft fracture.

OBJECTIVE: The purpose of this study was to investigate the effect of rotational deformities on patellofemoral alignment using the dynamic magnetic resonance imaging method on patients whose femur fractures were treated with intramedullary locking nails. METHODS: The dynamic patellofemoral magnetic resonance imaging results of 33 patients (5 females and 28 males) were reviewed. The mean age of the patients was 36.3 (range 19-61) years. The mean follow-up was 30.2 months (range 24-38). All the patients were given Kujala patellofemoral clinical evaluation scores at the latest follow-up. Those with less than 10° of rotational deformity in either direction were classified as Group A, those with more than a 10° of internal rotation deformity as Group B and more than a 10° of external rotation deformity as Group C. The three groups were then compared regarding to clinical scores. Patellofemoral parameters of operated and contralateral side were also compared in each group. RESULTS: There were 14 (42.4 %) patients in Group A, 12 (36.4 %) patients in Group B and 7 (21.2 %) patients in Group C. The mean patella score in Group C (74 ± 7.02) was significantly lower when compared with Group B (87.6 ± 9.9) and group A (90.6 ± 6.1) (p < 0.05). In Group C patients, medial patellar tilt was detected when compared with the intact side. There were no significant changes in patellofemoral position in either Group A or Group B. CONCLUSION: The results of this study revealed that more than 10° of external rotation deformity could cause a detoriation in the patellofemoral scores. Anatomic reduction of the fracture site should be performed as soon as possible and external rotational deformities should especially be avoided in order to prevent patellofemoral malalignment.

Short-term clinical and radiologic results of the scarf osteotomy: what factors contribute to recurrence?

The present retrospective investigation aimed to determine the factors associated with recurrence of hallux valgus deformity after scarf osteotomy in 50 feet in 43 consecutive patients. We hypothesized that hallux abductovalgus after scarf osteotomy recurs because of the presence of preoperative joint incongruity. The clinical and radiographic findings, including the weightbearing radiographic hallux valgus angle, first intermetatarsal angle, distal metatarsal articular angle, first metatarsophalangeal joint congruence, American Orthopaedic Foot and Ankle Society scores, and pain measured on a visual analog scale, and logistic regression analysis were used to analyze the association of the independent variables with the recurrence of deformity. The mean age of the patients was 47.7 (range 21 to 65) years, and the mean follow-up duration was 26.2 (range 18 to 36) months. The mean American Orthopaedic Foot and Ankle Society scores improved from 50.7 ± 4.9 to 88.7 ± 7.9, and the visual analog scale pain scores improved from 7.5 ± 1.1 to 2.4 ± 1.0 (p < .05). The changes in the radiographic measurements were also statistically significant. Of the 50 feet, 5 (10%) developed recurrent hallux abductovalgus, each of which occurred in feet that had displayed a first metatarsophalangeal joint incongruity on preoperative radiographs. The incongruity was observed to be a statistically significant risk factor for recurrence according to the regression models. From our experience with the patients analyzed in the present report, we believe that first metatarsophalangeal joint congruity should be given particular attention when surgical correction of hallux abductovalgus is undertaken.

Factors affecting the closed reduction of diaphyseal fractures of the femur.

INTRODUCTION: This level II prospective study investigates patient and fracture-related factors likely to affect closed reduction time in the surgical treatment of femur fractures, and the effect these factors have on closed reduction time. PATIENTS AND METHODS: Seventy-nine diaphyseal femur fractures of 75 patients were included in the present study. All fractures were treated with indirect closed reduction by manual traction using antegrade nailing and static, locked, reamed intramedullary nails. The three variables considered to influence the duration of closed reduction, that is, the type of fracture, BMI, and the preoperative period (time from injury to surgery), were evaluated either separately or in a combination of two or three of the variables. Their influence on the closed reduction time was analyzed and evaluated. RESULTS: In this study according to the outcomes, a preoperative period ≤24 h had a significant effect in shortening the reduction time. The reduction time was not significantly affected by the type of fracture. The reduction time was prolonged in overweight patients, but the difference was not significant. When the three variables BMI, preoperative period, and fracture types were evaluated together, the common effect of these three variables was not significant. CONCLUSION: In conclusion, based on these results, we think that closed reduction should certainly be aimed for in femur fractures in which intramedullary nailing is planned. Also, early surgical intervention appears to have a beneficial effect on the success of closed reduction.

Unexpected injury of the orthopaedic surgeon: a case report of a hammer splinter.

Sharps injuries have become one of the most important occupational injuries and they are common during surgery, with rates between 1.7 and 6.9% of all surgical procedures. This case report, however, revealed an extremely rare and unexpected condition, which could not be prevented by the reasonable safety precautions against injury. Closed reduction and closed intramedullary fixation was planned for the patient with humeral shaft fracture. While advancing the nail by hammering a piece of metal detached. A short time following the commencement of the procedure, the surgeon who was performing the operation felt a sudden severe pain in the neck. A radio-opaque intensity in the cervical region was detected on X-rays. There was a piece of metal from the hammer. The risk encountered in the present case comprises a condition, the prevention of which is probably impossible with the frequently utilized preventive measures against injuries. For this reason, the operating room team and in particular, the surgeon, should be careful about possible expected injuries, as well as the unexpected ones. Sharps injuries continue to be a serious concern for all healthcare workers. In some studies however, reporting of sharps injuries by healthcare workers remains a problem with reporting levels cited as low as 15% and as high as 90% (Kerr H-L, Stewart N Ann R Coll Surg Engl 91:430-432, [6]). Guo et al. pointed out the most recent sharps injuries at work, and syringe needles was by far the most important items causing injuries, followed by glass products, suture needles, and intravenous catheters.

Influence of direct radiography in decision making during orthopaedic trauma surgery: A prospective study.

Objective: To evaluate the effects of intraoperative direct radiography on the change in the patient's treatment and the reliability of fluoroscopy in orthopaedic trauma surgery operations. Methods: A total of 773 fractures were evaluated prospectively. The surgeons involved in the case were divided into three groups according to their experiences: less than 5 years, 5-10 years and over 10 years. After each case, the fracture classification, whether any interventions were made after the X-ray, and the interventions were recorded. Results: There were 312(40%) intra-articular, 200(26%) metaphyseal, 161(21%) diaphyseal, 81(10%) pelvis-acetabulum, and 19(3%) vertebrae fractures. Surgeons needed to intervene in 71(9.2%) cases after direct-radiography. There was a significant difference between the location of the fracture and the number of interventions (p < 0.001). The most frequent interventions were intra-articular distal radius, acetabulum and intra-articular calcaneus fractures, respectively. Surgeons with more than 10 years of the experience felt the need to make fewer changes, it was statistically significant compared to the other two groups (p = 0.001 for both). Conclusion: It was found that the final evaluation with x-ray images before the operation was completed in trauma surgery affected the surgeon's decision. In particular, intra-articular fractures, acetabular fractures, and vertebral fractures are recommended to evaluate fixation with direct radiography in addition to fluoroscopy images before ending the operation. Level of evidence: LEVEL III.

The Impact of Surgical Approaches for Isolated Acetabulum Fracture on Sexual Functions: A Prospective Study.

OBJECTIVES: To investigate the effects of surgical modalities for isolated acetabular fractures on the sexual functions of patients and their partners. DESIGN: Prospective. SETTING: Level I trauma centre. PATIENTS/PARTICIPANTS: Sixty-five patients who had undergone open reduction and internal fixation because of isolated acetabular fractures who were sexually active before, together with their partners. INTERVENTION: Patients operated on for isolated acetabular fractures were divided into 3 groups according to surgical approaches: the Kocher-Langenbeck approach (n = 36), ilioinguinal approach (n = 16), and modified Stoppa approach (n = 13). MAIN OUTCOME MEASUREMENTS: Sexual functions of patients and their partners were evaluated with the 5-item version of the International Index of Erectile Function score and Female Sexual Function Index score preoperatively and at the postoperative first year after the rehabilitation period. RESULTS: The mean age of the patients was 41.8 ± 13.0 (18-69) years. In male patients, the mean 5-item version of the International Index of Erectile Function score had changed from 24.3 to 20.0 at the postoperative first year and the decrease in sexual function scores was less with the Kocher-Langenbeck approach. In female patients, the Female Sexual Function Index scores had decreased statistically significantly from 24.9 to 18.3 at the postoperative first year, but there was no statistically significant difference between surgical groups. Both male and female patients' partners' sexual function scores were also decreased at the postoperative first year. CONCLUSIONS: As a result of our study, it was observed that the posterior approach is more advantageous than anterior approaches in preserving the sexual functions of male patients in acetabular fracture surgery. However, the surgical approach did not affect the sexual functions of female patients. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Comparison of the first and second waves of the COVID-19 pandemic with a normal period in terms of orthopaedic trauma: Data from a level 1 trauma centre.

OBJECTIVE: The aim of this study was to compare the characteristics and distribution of trauma surgeries performed in the first phase of the COVID-19 pandemic, the second phase of the pandemic, and the normal period before the pandemic. METHODS: Three different time periods were determined.Group 1 represented the first wave of the pandemic, in which lockdowns andrestrictions were strictly applied and only emergency and trauma surgeries wereperformed, between 1 April and 31 May 2020. Group 2 represented the second waveof the pandemic, during which restrictions were not applied and only emergencyand trauma surgeries were performed, from 1 September to 31 October 2020. Group3 represented the normal period before the pandemic, including surgeriesperformed between 1 September and 31 October 2019. In addition, patients ineach group were divided into two groups as younger than 16 or older than 16 inorder to understand the difference between paediatric and adult orthopaedictraumas. The distribution of patients and their fractures were evaluated. RESULTS: In Group 1, the rates of intra-articular fractures, distal extremity fractures, and proximal humerus fractures decreased, while the rate of proximal femur fractures increased (P < 0.05 for all). The frequency of hand fractures treated in Groups 1 and 2 compared to Group 3 was reduced (P < 0.05 for both). There was no statistically significant difference between Groups 2 and 3 for fractures in different parts of the body except for hand fractures (P = 0.001 for hand fractures, P > 0.05 for the other fractures). CONCLUSION: We observed that the frequency of fractures decreased, and the distribution changed due to severe restrictions and lockdowns in the first wave of the pandemic. When the restrictions and lockdowns were removed in the second wave, the frequency of fractures decreased, but the distribution of fractures was similar to the normal period in 2019. LEVEL OF EVIDENCE: Level III, Diagnostic Study.

May minimally invasive plate osteosynthesis be an alternative to intramedullary nailing in selected spiral oblique and spiral wedge tibial shaft fractures?

OBJECTIVES: This study aims to compare intramedullary nailing (IMN) and minimally invasive plate osteosynthesis (MIPO) treatment methods in Arbeitsgemeinschaft für Osteosynthesefragen (AO) 42A1 & 42B1 selected tibial shaft fractures. PATIENTS AND METHODS: Fifty-one patients (31 males, 20 females; mean age 43.5±14.2 years; range, 18 to 81 years) operated for AO 42A1 or AO 42B1 tibial shaft fractures between January 2006 and January 2012 were retrospectively evaluated. Twenty-three of these patients were treated with MIPO and 28 with IMN. Patients were compared in terms of union time, return to work, infection, malunion, hospital stay, and sixth month and two-year Lower Extremity Functional Scale (LEFS) values. RESULTS: There was no difference between the MIPO and IMN groups in terms of demographic data, etiology, and fracture patterns. The mean follow-up time was 37.8±8.8 months in MIPO group and 35.9±8.7 months in IMN group. Union time (p=0.575), return to work (p=0.155), infection (p=0.643), malunion (p=0.471), and hospital stay (p=0.538) were all similar between groups. Although the LEFS value was higher in IMN group in sixth month (p=0.026), the two-year LEFS value was similar between groups (p=0.085). CONCLUSION: Results of the study showed that both treatment methods are similar regarding clinical and functional outcomes. According to these results, MIPO can be recommended as an alternative to IMN in tibial shaft fractures formed as spiral oblique and spiral wedge.

Effects of morphological changes in the patellar tendon on the development of anterior knee pain after intramedullary nailing for tibial shaft fractures: A retrospective comparative study.

OBJECTIVE: This study aimed to investigate the effects of morphological changes of the patellar tendon (length, width, and thickness) on the development of anterior knee pain (AKP) after intramedullary nailing (IMN) of tibial shaft fractures. METHODS: A total of 39 patients, treated by IMN using the transpatellar approach for tibial shaft fractures, were retrospectively reviewed and included in the study. The patients were then divided into 2 groups based on the presence of AKP: group A, patients who developed AKP (9 men, 9 women; mean age=35.39±9.32 years), and group B, patients without AKP (13 men, 8 women; mean age=41.38±14.78 years). To assess the morphological changes in the patellar tendon, magnetic resonance imaging was performed on the operated and unoperated, contralateral knees of the patients. The patellar tendon index (PTI) was calculated using the length, width, and thickness of the patellar tendon, and a set of variables was established to be a proportion of the measurements of the operated knees to those of the unoperated ones (operated/healthy PTI ratio). PTI ratios were compared between both the groups. Furthermore, the morphological features of the patellar tendon, including the length, width, and thickness, were examined within the groups as independent variables. To assess pain intensity in group A, a 10-cm visual analogue scale (VAS) was used. To evaluate functional status, the Lysholm knee scoring system was used. RESULTS: The PTI ratio was significantly higher in group A (1.37±0.12) than in group B (1.03±0.08) (p<0.001). In group A, the mean VAS score was 5.35±1.11, and a moderate linear correlation was found between PTI ratios and VAS scores (r=0.494, p=0.044). The mean Lysholm score was significantly lower in group A (80.17±3.05) than in group B (89.76±3.05) (p<0.001). In group A, the width and thickness of the patellar tendon were found to be significantly different between the operated and unoperated knees (p=0.024 and p=0.002, respectively). In group B, there was no difference between the operated and unoperated knees in terms of the 3 measurements (length, width, and thickness) (p=0.762, p=0.753, and p=0.118, respectively). CONCLUSION: Evidence from this study revealed that morphological changes occurring in the patellar tendon after IMN for tibial shaft fractures using a transpatellar approach may have a significant role in the development of AKP. The increase in the tendon width and thickness may be the cause of pain and insufficient knee function in such patients. LEVEL OF EVIDENCE: Level III, Therapeutic study.

Treatment strategies of defect nonunion with vascular damaged by induced membrane technique: Is two-stage treatment sufficient?

INTRODUCTION: Defect nonunion is often associated with vascular damaged, concomitant infection and unfavorable soft tissue. Although several procedures used for bone defect nonunion, recently the induced membrane (IM) technique has gained great popularity in the world. The aim of this article is to evaluate the efficacy of vascular damaged nonunions with treated IM technique. PATIENTS AND METHODS: This retrospective study included tibial defect nonunions of twenty-four patients (22 men, 2 women) with treated IM technique, from January 2014 to December 2018. According to the angiography of the extremity, a decrease in blood flow or obstruction in arterial vessels was suggested as vascular damaged group (n = 11) (Group 1), without vascular damaged group (n = 13) (Group 2). All surgeries applied during IM technique treatment including start with cement insertion and until last control were defined as number of surgeries. RESULTS: The average time to union (40.18 ± 10.01 weeks - 38.61 ± 11.20 weeks) and the mean defect size (6.54 ± 1.75 cm - 6.61 ± 1.85 cm), no statistical differences were found between 2 groups (p >0.05). The average of spacer use was 11.27 (6 to 16) and 7.23 (6 to 10) weeks in group 1and 2, respectively. The mean number of surgeries was 3.91 ± 0.83 (at least 3 and at most 5) in group 1 and 2.31 ± 0.48 (2 to 3) in group 2. CONCLUSION: Although nonunions with vascular damage may require more surgeries and duration to spacer, a similar time to union and union rate were achieved compared to without vascular damage.

An Overlooked Deformity in Patients with Hallux Valgus Tailor's Bunion.

BACKGROUND: Tailor's bunion is a deformity of the fifth toe, and its concomitance with hallux valgus (HV) is defined as splayfoot deformity. Treatment is focused on the HV deformity in splayfoot, and the tailor's bunion deformity can be overlooked. The frequency of HV concomitant with tailor's bunion in splayfoot has not been reported in the literature. METHODS: A retrospective evaluation was performed to detect the existence of tailor's bunion deformity in 203 patients (376 feet) treated for HV. Standing anteroposterior and lateral radiographs were used in the radiologic evaluation. Fallat's classification was used to grade tailor's bunion. Surgery for HV was applied to 86 patients (136 feet), and conservative treatment was applied to 117 patients (240 feet). Mean follow-up was 28.3 months (range, 18-42 months). Clinical evaluation was by American Orthopaedic Foot and Ankle Society (AOFAS) score. RESULTS: Of the 376 feet with HV, 28 (7.4%) had tailor's bunion, of which 17 (60.7%) were overlooked according to the surgery criteria for tailor's bunion. In the HV surgery group, there were no differences in preoperative mean AOFAS scores according to concurrence with tailor's bunion, but postoperative AOFAS scores were low in patients with accompanying tailor's bunion (P < .001). In the conservative group, no differences were determined in mean AOFAS scores according to tailor's bunion. CONCLUSIONS: Tailor's bunion deformity sometimes goes undiagnosed in patients with treated HV. This deformity must be kept in mind for patients with HV to improve clinical results.

Finite element analysis of the stability of transverse acetabular fractures in standing and sitting positions by different fixation options.

BACKGROUND: Treatment of a transverse acetabular fracture type is possible from an anterior approach, a posterior approach or both. Different fixation methods have been described but whether one is superior to the other is still under debate. The aim of the current study was to test the different fixation alternatives of stabilization of transverse acetabular fractures under two basic physiological loading conditions: standing and sitting utilizing a finite element model. MATERIAL AND METHODS: A transtectal transverse fracture model was fixed in five different alternatives: an anterior column plate; a posterior column plate; an anterior column plate combined with a posterior column screw; a posterior column plate combined with an anterior column screw; and a posterior column plate and an anterior column plate. In these models, a load of 400N was applied at standing and sitting positions and the displacements were analyzed by using three-dimensional finite element stress analysis method. RESULTS: In the model simulating standing human position, overall motion at the posterior column was minimum when two columns were plated (0.071mm). The second best fixation was posterior column plate with an anterior column screw (0.077mm). Overall motion at the anterior column was minimum by posterior column plate with an anterior column screw (0.0326mm). The plating of two columns was associated with motion of (0.0333mm). In the model that simulates sitting position, the motion at the posterior column was minimum when two columns were plated (0.0478mm), and (0.0517mm) when a posterior column plate with an anterior column screw was used. Overall motion in the anterior column was minimum when posterior column plate with an anterior column screw (0.0198mm) was used, whereas the motion was (0.0203mm) when plating of both columns was examined. CONCLUSION: Posterior column plating combined with an anterior column screw has quite comparable results to a both column plating in transverse fractures, suggesting that two column fixations might be unnecessary. This method is also very superior to anterior column plating combined with a posterior column screw in that type of fractures.

An Unusual Disengagement of the Humeral Head Component after Hemiarthroplasty: A Case Report Presentation.

INTRODUCTION: Proximal humeral fractures account for 4% to 5% of all fractures. Complex proximal humeral fractures with displaced three- and four-part fragments, humeral head splits and fracture-dislocations are more difficult to treat. In older patients, because of poor bone quality, hemiarthroplasty is often the indicated treatment. CASE REPORT: One such case of a 73-year-old woman is presented here. The patient presented with a four-part fracture of the proximal humerus, with displacement of the humeral head. Hemiarthroplasty was done in the right shoulder. At postoperative 20 days, during physical therapy, the humeral head component of the prosthesis disengaged and a second operation was necessary. A deltopectoral approach was repeated using the previous incision. The humeral stem was seen to be well-fixed into the bone so the humeral head was changed for a new one of the same size. At two years, the dominant right side had active, painless ROM. CONCLUSION: The management and two-year follow-up of this case is reported here, which was the first to occur at our institution.

Acromioclavicular reconstruction using hook plate and anterior tibial tendon allograft with triple tunnel: The early results of revision surgery using a novel surgical technique.

In this study, a new modified surgical technique is presented for anatomic acromioclavicular (AC) joint reconstruction made by the application of anterior tibialis tendon autograft, three-way tunnel (two clavicular and one coracoid) and hook plate. The study is aimed to evaluate the post-operative short-term results of patients who underwent this treatment. A total of 11 patients underwent AC joint reconstruction because of persistent AC subluxation. In this reconstruction, a triple tunnel was made between the coracoid and the clavicle to anatomically restore the coracoclavicular (CC) ligament and an allograft was passed through the tunnels resembling conoid and trapezoid ligaments. The tendon had to be non-weight bearing at the appropriate tension to provide rapid and appropriate integration of the tendon in the tunnel. This was maintained by applying a hook plate. The hook plate method was used to protect the reconstructed ligament during the healing process as it has a similar hardness to that of the natural AC joint and provides rigid fixation. For a more comprehensive description of the technique, a cadaver demonstration was also performed. The mean follow-up period was 25.3 months (range: 18-34 month). None of the patients had a loss of reduction at the final follow-up. When the constant scores were examined, of the total 11 patients, 2 (18.2%) 38,39 had excellent results, 6 (54.5%) had good results and 3 (27.3%) had fair results. It can be seen that this newly described reconstruction technique has successful short-term results as an anatomic method and can be used effectively in revision cases. However, there is a need for further biomechanical and clinical studies to make comparisons with other techniques.

Avoiding iatrogenic radial nerve injury during humeral fracture surgery: a modified approach to the distal humerus.

OBJECTIVE: Our aim was to assess the results of posterior retraction technique to prevent iatrogenic radial nerve injury during humeral fracture surgery. METHODS: Seventy-two patients who underwent surgery for a distal humerus fracture between 1996 and 2002 were reviewed. These 72 patients comprised Group 1. Following a cadaveric study on the vascularization of the radial nerve, a modified surgical approach was undertaken starting in 2002. Sixty-one patients who underwent this new surgical approach were included in Group 2. The rates of radial nerve deficit of the groups were compared using the Pearson chi-square test. RESULTS: In Group 1, 19 iatrogenic nerve deficits occurred. After defining the blood circulation of the nerve, the lateral approach was modified. The anterolateral side of the nerve was released and the nerve was left attached to the triceps muscle. In Group 2, one patient developed postoperative transient nerve deficit. CONCLUSION: The radial nerve is supplied by the branches of the deep brachial artery in close relation with the triceps muscle. Anterior dissection and posterior retraction of the radial nerve during lateral approach may preserve its blood supply and reduces the risk of iatrogenic injury.