Effects of hyperbaric oxygen therapy on rabbit skeletal muscle during extremity lengthening.

INTRODUCTION: Extremity lengthening through distraction osteogenesis is limited by the surrounding skeletal muscle and neurovascular structures rather than the bone itself. The purpose of this study is to evaluate the effects of hyperbaric oxygen therapy on skeletal muscle during distraction osteogenesis. MATERIALS AND METHODS: Twenty New Zealand white rabbits were randomly divided into two groups. Right tibia of all rabbits was distracted at a rate of 0.125 mm per 6 h (0.5 mm/day) for 10 days with circular external fixator. Experimental group rabbits (N=10) underwent 2.5 ATA hyperbaric oxygen therapy for 2 h everyday for 20 days, control group rabbits (N=10) did not receive any corresponding treatment. Skeletal muscle perfusion was evaluated with scintigraphy before and after the distraction period. Serum CPK, LDH and AST levels were measured before and after the distraction period. All animals were killed on the 27th day. The right tibias of all animals were removed and tibialis posterior muscle was harvested for histopathologic and histomorphometric assessment with light and electron microscopy. RESULTS: Skeletal muscle perfusion was decreased in the control group in comparison with pre-distraction level (P=0.008). However, no significant decrease was observed in the experimental group (P=0.678). There were no statistical differences in serum CPK, LDH and AST levels between groups (P=0.340, P=0.077, P=0.796). The mean area of the muscle fibers was measured as 398.66+/-9.16 micro2 in the experimental group and 349.44+/-5.76 micro2 in the control group (P=0.000) with light microscopy. Mild fibrosis was observed in connective tissue component of muscle tissue in control group. An average of 26 myofibrils (20-32) was counted in a 16-cm2 unit area in experimental group and 50 myofibrils (35-65) in the control group with electron microscopy. Enlargement in the sarcoplasmic reticulum, degenerative changes in nuclear cytoplasm and increase in myofibril diameter were observed in the control group, which was not observed in the experimental group CONCLUSION: Results of this study suggest that HBO treatment alleviates the detrimental effects of distraction on skeletal muscles and preserves its ultrastructure.

[The results of arthroscopically assisted circular external fixation in bicondylar tibial plateau fractures]. / Bikondiler tibia kiriklarinda artroskopi destekli eksternal fiksatör osteosentezi sonuçlari.

OBJECTIVES: We evaluated the results of arthroscopically assisted circular external fixation in bicondylar tibial plateau fractures. METHODS: The study included 13 patients (12 males, 1 female; mean age 27 years; range 18 to 37 years) who were treated with circular external fixation under arthroscopic control for bicondylar tibial plateau fractures. The causes of fractures were traffic accidents in nine cases, sport injuries in two cases, and fall from height in two cases. Eight patients had open fractures. The mean time from injury to presentation was two days. Soft tissue injuries were treated with curettage and excision. The fractures were classified according to the Schatzker's system. Functional results were assessed using the knee scoring system of Lysholm and Gillquist. The mean follow-up period was 35 months (range 16 to 38 months). RESULTS: There was no neurovascular pathology in any of the cases preoperatively and postoperatively. Lysholm and Gillquist knee scores were very good in two patients, good in six patients, moderate in four patients, and poor in one patient. The mean knee score was 82.46. The patient with the poor result had significant limitation in knee extension and flexion. Postoperative complications included superficial soft tissue infection in two patients and pin tract infection in six patients. CONCLUSION: Arthroscopically assisted circular external fixation of bicondylar tibial plateau fractures is efficient to obtain satisfactory functional results.

Modified crescentic proximal metatarsal osteotomy and distal soft tissue procedures in hallux valgus.

The results of a modified crescentic proximal metatarsal osteotomy and distal soft tissue procedures for patients with symptomatic, incongruent, metatarsophalangeal joint, hallux valgus deformity were reviewed. Forty-nine feet of 41 patients were evaluated. All of the patients were male military personnel of different ranks, and their mean age was 23 years (range, 20-43 years). The mean follow-up period was 25 months (range, 10-60 months). The patients were evaluated according to the American Orthopedic Foot and Ankle Society forefoot scoring system. The mean preoperative score was 54.4, and the mean postoperative score was 95.4. The mean hallux valgus angle was 39.4 degrees before surgery and 12.8 degrees after surgery (26.6 degrees correction); the mean intermetatarsal angle was 15.9 degrees before surgery and 7.1 after surgery (8.8 degrees correction). A total of 93.8% of the patients were satisfied with the results of the procedure. Complications included delayed union in one case and superficial wound infections in two cases. We also emphasize small modifications performed while shifting the metatarsal shaft laterally and compare the results of our study with those of similar studies.

[Treatment of AO type C2-C3 fractures of the distal end of the radius with external fixation]. / Radius distal uç kiriklarinin (AO tip C2-C3) eksternal fiksatörle tedavisi.

OBJECTIVES: We evaluated the results of combined treatment with closed reduction, grafting, K-wires, and external fixation in patients with fractures of the distal end of the radius. METHODS: Of 24 patients (15 males, 9 females; mean age 34 years; range 21-73), 16 patients had C2, eight patients had C3 fractures according to the AO classification. Three patients had open fractures, and four patients had signs of median nerve compression. Treatment included closed reduction, autologous grafting (16 cases) followed by fixation with 2 to 5 K-wires, and an external fixator. Clinical and radiographic results were assessed according to the Gartland-Werley's and Stewart's criteria, respectively, and degenerative changes to the Knirk-Jupiter's criteria. The mean follow-up was 35 months (range 25 to 52 months). RESULTS: All of the 19 patients who were employed returned to preinjury working conditions in a mean of 3.5 months. Radial length was preserved to a great extent. The mean amount of collapse of the joint surface was 1.4 mm. The mean loss was 6.7% in radial inclination, and 17.6% in the volar tilt. According to the Stewart's criteria, the results were good, moderate, and poor in 12, nine, and three patients, respectively. Flexion-extension (75%), supination-pronation (70%), and radial-ulnar deviation (75%) were preserved to a great extent. Grip force amounted to 70% of the healthy side. According to the Gartland-Werley criteria, three patients had excellent, eight patients had good, 10 patients had moderate, and three patients had poor results. According to the Knirk-Jupiter's criteria, degenerative changes were slight in 11 patients, moderate in six patients, and severe in one patient. Six patients had no signs of degeneration. Complications included pin track infections (n=4), early transient reflex sympathetic dystrophy (n=2), and hypoesthesia along the superficial branch of the radial nerve (n=2). CONCLUSION: Treatment of the distal end fractures of the radius (AO type C2-C3) with a combination of external fixation, grafting, and percutaneous K-wires provides almost normal radiologic and clinical parameters.

[Management of fibular hemimelia with the Ilizarov circular external fixator]. / Fibular hemimelia: Ilizarov sirküler eksternal fiksatörü ile tedavi sonuçlari.

OBJECTIVES: We evaluated the results of treatment with the Ilizarov circular external fixator for limb length inequality and deformities in patients with type IA, IB, and type II fibular hemimelia. METHODS: Tibial corticotomy and distraction osteogenesis with the Ilizarov technique were performed in five male patients (mean age 11.4 years; range 4 to 20 years). According to the classification of Achterman and Kalamchi, fibular hemimelia was type IA, IB, and II in three patients, one patient, and one patient, respectively. Involvement was on the right in three patients, and on the left in two patients. Two patients had equinus and one patient had valgus deformities. No instability existed in the ankle and knee joints. The mean leg discrepancy was 8.7 cm (range 3 to 16.5 cm), and the mean lengthening index was 1.6 cm/month (range 1.4 to 2 cm). The mean follow-up was 33 months (range 15 to 68 months). RESULTS: On final examinations, full range of motion of the knee was obtained. A plantigrade foot was achieved in three feet, while two sustained an equinus deformity of 17 and 15 degrees, respectively. Pin tract infections were observed in four patients, all of which were treated with oral antibiotics and dressing. During distraction, three patients had pain. Two patients had a limited range of motion of the ankle joint, without instability or subluxation of the ankle and knee joints. These joint problems were successfully dealt with by physical exercises. CONCLUSION: The Ilizarov technique is a convenient method in the correction of angular and rotational deformities while enabling distraction in type I and type II fibular hemimelia.

[Psychiatric symptoms in patients treated with an Ilizarov external fixator]. / Ilizarov eksternal fiksatörü uygulanan hastalarda psikiyatrik belirtiler.

OBJECTIVES: The Ilizarov technique limits daily activities of patients and may cause psychiatric symptoms. We investigated psychiatric symptoms associated with the use of an Ilizarov circular external fixator (CEF) and the relationship between symptoms and duration of CEF application in adult patients. METHODS: The study included 40 adult male outpatients (mean age 26.4 years; range 20 to 40 years) who were treated with a CEF. The participants were administered a questionnaire on sociodemographic and clinical characteristics. Psychiatric symptoms were assessed using the Symptom Check List (SCL-90-R). Data were compared with those of a control group consisting of 30 healthy males with similar sociodemographic features. RESULTS: Significant differences were found between the patient and control groups with regard to somatization (p=0.03), interpersonal sensitivity (p=0.027), depression (p=0.003), anxiety (p=0.025), hostility (p=0.004), paranoid ideation (p=0.021), additional scale (p=0.000), and overall symptom (p=0.024) scores. There was at least one psychiatric symptom in 52.5% of the subjects treated with a CEF. Hostility, interpersonal sensitivity, sleep disturbances, obsessive-compulsive signs, and anxiety were detected in 37.5%, 35%, 32.5%, 20%, and 20%, respectively. The duration of CEF application was positively correlated with depression and interpersonal sensitivity (p=0.000), and negatively correlated with anxiety (p=0.001). CONCLUSION: Our data demonstrate that, during treatment with a CEF, psychiatric problems emerge, which warrant careful evaluation of the psychiatric condition of the patients.

[Comparison between the distraction and grafting methods in the treatment of peripheral neural defects: an experimental study in rabbits]. / Periferik sinir defektlerinin tedavisinde distraksiyon ve greftleme yöntemlerinin karsilastirilmasi: Tavsanda deneysel çalisma.

OBJECTIVES: We compared the electrophysiologic and histopathologic results of grafting and distraction methods in the treatment of defective peripheral neural injuries. METHODS: Thirty male white rabbits (age 6 months) were divided into three groups and a circular external fixator (CEF) was applied to the right tibias. In group I (primary repair), the right deep peroneal nerve was cut without inducing any defect and a tibial osteotomy was performed. The remaining groups underwent bone and nerve excision of about 1 cm in the middle third of the tibia. In group II, the defect area was closed acutely with the CEF and the continuity of the nerve was restored. In group III, a nerve graft obtained from the left side was placed in the defect area and an epiperineural repair was made. Group II underwent distraction 21 days after surgery for 10 days with a rate of 0.25 mm four times a day. Electrophysiological studies were performed in the 12th and 24th weeks and nerve biopsies were obtained in the 32nd week for histopathologic examination. RESULTS: Electrophysiological studies in the 12th week did not show any significant differences in nerve conduction between the three groups; however, in the 24th week, amplitude and latency values of the graft group were 50% lower than those of the primary repair and distraction groups (p<0.05). On histological examination, the results were good in group I and II, but poor in group III with respect to nerve fiber density, thickness of the myelin sheath, degenerative changes in the myelin sheath, and average axon number. CONCLUSION: Our data demonstrate that treatment of neural defects by the distraction method results in much better results than the grafting method.

High-velocity gunshot wounds of the tibial plafond managed with Ilizarov external fixation: a report of 13 cases.

OBJECTIVE: To report the results of using Ilizarov fixation for the treatment of open tibial plafond fractures caused by high-velocity gunshot injuries. DESIGN Retrospective review of consecutive patients. SETTING: Military academic hospital. PATIENTS: Using the AO classification, three type C1, five type C2, and five type C3 open tibial plafond fractures due to high-velocity gunshot injuries were treated with irrigation, débridement, primary closure, and Ilizarov fixation. Eleven of the fractures were type IIIA, and the remaining two were type IIIB according to the Gustilo-Anderson classification. There were also multiple traumas in one case. METHODS: Plafond fractures were treated by Ilizarov technique in all 13 cases. In three of the cases, additional osseous transport to eliminate a skeletal defect was performed. MAIN OUTCOME MEASURES: Results were evaluated according to Bone's clinical grading system. RESULTS: Average follow-up was 38.4 months (range 26 to 50 months). Callus began to form in 21 to 35 days (average 27.9 days). The fractures united in 126 to 154 days (average 137.6 days), and the apparatus was removed from the limb at that time. There were six good, three fair, and four poor results. Minimal skin necrosis around the wound was seen in four cases, wound infection and purulent discharge were seen in two cases, and angular deformity was seen in two cases. Delayed union and reflex sympathetic dystrophy were not seen in any cases. Although tibiotalar narrowing was seen in four cases, no cases required tibiotalar arthrodesis or subsequent bony reconstruction at the time of their most recent follow-up. The average residual ankle range of motion was plantar flexion 18.5 degrees and dorsiflexion 11.5 degrees. CONCLUSIONS: Early aggressive débridement of nonviable tissues, stabilization with an Ilizarov external fixator, and either primary or delayed primary closure followed by early ankle range of motion and weight bearing is an alternative treatment method of these injuries.

Treatment results for open comminuted distal humerus intra-articuler fractures with Ilizarov circular external fixator.

In open, intra-articular distal humerus fracture caused by gunshot injury, full functional recovery is difficult to obtain. Three basic treatment methods are available: minimal internal fixation, open reduction-internal fixation, and external fixation. In Gülhane Military Medical Academy Department of Orthopedics and Traumatology, 19 of 20 cases of gunshot injuries were treated with circular external fixator between the January 1995 and December 2000. Nine (45%) cases were type III-A, eight (40%) were type III-B, and three (15%] were type III-C. Eight (40%) cases were brought to the hospital 6 to 8 hours after the injury and 12 (60%) were in late stage. An amputation was done in one case. Mean follow-up period was 34.3 (14-55) months. Union was achieved in all 19 of the cases, and circular external fixator was taken out in a mean period of 4.6 (3-7) months. In the early treatment group, three (42.9%) were good, three (42.9%) were moderate, and one (14.2%) was unsatisfactory. In the late treatment group, five (41.7%) were good, four (33.3) were moderate, and three (25%) were unsatisfactory. Circular external fixator can be preferred as a treatment alternative in selected cases of distal humerus intra-articular open communited fractures because it protects the soft tissue connections and blood circulation of bone fractured, permits early elbow movements, and allows the patient to return to daily life very early.

Major surgery and anesthetic technique in epidermolysis bullosa.

Epidermolysis bullosa is a hereditary rare condition characterized with local and generalized lesions and autosomal dominant trait with variable penetrance. It was decided to amputate the left leg under the knee of a female patient with epidermolysis bullosa with squamous cell carcinoma. The smallest trauma may cause formation of serious bullous in the skin in epidermolysis bullosa. Surgeons, dermatologists, and anesthesiologists must evaluate the cases. During preoperative, intraoperative, and postoperative periods, all interventions that may cause interruption in circulation of the tissues cause irritation, or delay healing of the wounds must be avoided.

The treatment of infected tibial nonunion with aggressive debridement and internal bone transport.

Tibial nonunions are a challenging situation for both healing and reconstruction when infection is added. In this retrospective study, we discuss the cases in which we had managed to obtain union by aggressive debridement, circular external fixature, and internal bone transport. Fourteen cases had been treated between January 1995 and December 2000 in the Orthopedics and Traumatology Department of the Gulhane Military Medical Academy. The mean follow-up period was 33.2 (12-60 months) months. The mean length of defects was 4.4 (2.5-8 cm) cm. These defects were repaired by corticotomy and by internal bone transport only. Pseudoarthrosis and union of corticotomy sites occurred in a mean period of 6.8 (4.5-15) months. In two of our patients, reinfection occurred, and hyperbaric oxygen therapy was applied to them. We concluded that in tibial infected nonunions, satisfactory union and control of infection are possible by radical debridement, stable fixation by circular external fixature, osteotomy and callus distraction, antibiotic therapy, and hyperbaric oxygen therapy whenever needed.

Depression in men with traumatic lower part amputation: a comparison to men with surgical lower part amputation.

This study aimed at comparing the prevalence of depression among traumatic and surgical amputees and examining the relationship between depression and sociodemographic/clinical characteristics of amputees. Participants were 49 patients with traumatic lower part amputation and 35 patients with surgical lower part amputation. The diagnosis of depression in each participating patient was confirmed by means of the Structured Clinical Interview for DSM-IV, Turkish version. The level of depression was assessed by using the Hamilton Depression Rating Scale. The prevalence of depression was 34.7% in the traumatic amputee group and 51.4% in the surgical amputee group (p > 0.05). In the traumatic group, depression was associated with time since amputation but not with other variables. However, in the surgical group, depression was associated with age, education level, marital status, economic status, time since amputation, and whether the patient was treated with prosthesis. Our data indicated that depression is a common clinical condition among amputees. Clinicians may be advised to schedule periodic contacts with amputees over long periods to identify those in need of psychiatric intervention.

Treatment of close-range, low-velocity gunshot fractures of tibia and femur diaphysis with consecutive compression-distraction technique: a report of 11 cases.

Lower extremity injuries secondary to close-range, low-velocity gunshot wounds are frequently seen in both civilian and military populations. A close-range, low-velocity injury produces high energy and often results in comminuted and complicated fractures with significant morbidity. In this study, four femoral, four tibial, and three combined tibia and fibular comminuted diaphyseal fractures secondary to close-range, low-velocity gunshot wounds in 11 military personnel were treated with debridement followed by compression-distraction lengthening using a circular external fixator frame. Fracture union was obtained in all without significant major complications. Fracture consolidation occurred at a mean of 3.5 months. At follow-up of 46.8 months, there were no delayed unions, nonunions, or malunions. Minor complications included four pin-tract infections and knee flexion limitation in two femur fractures. Osteomyelitis and deep soft tissue infection were not observed. This technique provided an alternative to casting, open reduction internal fixation, or intermedullary fixation with an acceptable complication rate.

[The treatment of comminuted midfoot fractures with distraction osteogenesis]. / Orta ayak bölgesi çok parçali kiriklarinin distraksiyon osteogenezi ile tedavisi.

OBJECTIVES: We evaluated the results of distraction osteogenesis with the Ilizarov circular external fixator in the treatment of comminuted fractures of the midfoot. METHODS: Four patients (1 female, 3 males) with comminuted midfoot fractures due to high energy trauma were treated with distraction osteogenesis performed by the Ilizarov circular external fixator. The mean age was 24 years (range 19 to 37 years). Fractures resulted from a traffic accident in one case, and from vehicle blast due to landmine explosion in three cases. The circular external fixator was applied for a mean of three months (range 2.5 to 4 months), during which the mean distraction was 10.5 mm (range 9 to 13 mm) at the fracture zone. The results were assessed according to the presence of pain and limping, radiographic measurements, and to the AOFAS (the American Orthopaedic Foot and Ankle Society) scoring system. The mean follow-up period was 58 months (range 33 to 81 months). RESULTS: All the patients had limping for a month following the removal of the fixator. At the end of six months, limping disappeared in one patient, decreased in two patients, and remained as a sequela in one patient. Pain which occurred during walking after the removal of the fixator decreased and finally disappeared within 3 to 6 months in three patients, but remained in one patient. Radiographic assessments were made using the anteroposterior and lateral X-rays of the foot. The mean AOFAS score was 70.5 (range 50 to 89). CONCLUSION: Distraction osteogenesis performed with the use of the Ilizarov circular external fixator may be an alternative in the treatment of comminuted foot fractures due to high energy traumas, where no other modality is likely to provide an anatomical reduction.

[The effects of surgical margins on local control and survival in extremity soft tissue sarcomas]. / Ekstremite yumusak doku sarkomlarinin tedavisinde cerrahi sinirlarin lokal kontrol ve sagkalim üzerine etkisi.

OBJECTIVES: We evaluated the effects of surgical margins and other prognostic factors on local control and survival in extremity soft tissue sarcomas. METHODS: The study included 40 patients (34 males, 6 females; mean age 45 years; range 13 to 77 years) who underwent treatment for extremity soft tissue sarcomas. Of these, 14 patients presented with recurrences following treatment elsewhere. Preoperatively, nine patients and eight patients; postoperatively, 35 patients and 25 patients received radiotherapy and chemotherapy, respectively. Limb-salvaging surgery was performed in 35 patients (87.5%), of whom 28 patients (70%) received an extended resection, and seven patients received a marginal resection. Five patients (12.5%) required amputation. Negative surgical margins were achieved in 34 patients (85%), while six patients (15%) had positive surgical margins. The mean follow-up period was 58 months (range 13 to 124 months). RESULTS: Five patients (12.5%) developed local recurrences following marginal resection (n=4), and amputation. No local recurrences were seen in patients receiving an extended resection or in those having negative surgical margins. Five-year survival rates were 51% and 49% in patients whose initial diagnoses were made in our department and elsewhere, respectively. Significant correlations were found between extended resection (p=0.0001) and negative surgical margins (p=0.0001) and local control; and between tumor grade and survival (p=0.002). Positive surgical margins and local recurrences did not decrease survival. CONCLUSION: Achievement of negative surgical margins promotes local control in extremity soft tissue sarcomas. A careful preoperative planning and utilization of neoadjuvant therapies highly increase the possibility of negative surgical margins.

[Evaluation of unilateral total hip arthroplasty by a quantitative analysis of gait]. / Tek tarafli total kalça artroplastisinin kantitatif yürüme analizi ile degerlendirilmesi.

OBJECTIVES: The purpose of this prospective study was to assess changes in gait parameters after unilateral total hip arthroplasty and to correlate these objective changes with the results of subjective analyses. METHODS: Thirty-eight patients (21 women, 17 men; mean age 61 years) with unilateral degenerative hip disease were evaluated in order to investigate preoperative and postoperative gait characteristics with the use of a gait evaluation mat (Gait Rite, USA). Each patient underwent at least two postoperative gait evaluations in the sixth and twelfth months, respectively. Gait evaluations were also made in a control group of 50 individuals without any neuromuscular and skeletal disease. Clinical evaluations were made using the Harris hip scoring system. RESULTS: All patients exhibited poor subjective evaluations preoperatively (Harris hip score <70). Compared to controls, patients had decreased step length and velocity, but increased stance, step, double support and swing times. Postoperatively, gait characteristics did not differ from those elicited prior to surgery in the first six months; however, patients attained near-normal velocity in the twelfth month. The recorded values for step length, step time, and double support time were similar to those of controls in both extremities. CONCLUSION: This study showed that total hip arthroplasty considerably improved the gait characteristics of patients with degenerative arthritis, and that this improvement could be measured and recorded quantitatively with the use of a walking band.

[Comparison of soft tissue and bone injuries caused by handgun or rifle bullets: an experimental study]. / Tabanca ve piyade tüfegi mermileri ile olusturulan yumusak doku ve kemik yaralanmalarinin karsilastirilmasi: deneysel çalisma.

OBJECTIVES: The aim of this study was to investigate the factors that influence the severity of soft tissue and bone injuries occurring in gunshot traumas and to compare the effects of handgun and rifle bullets on these injuries. METHODS: Sixteen tissue simulants which were made of transparent gel candle blocks and calibrated to muscle tissue were targetted by pistol (9 mm parabellum) or military rifle (G-3) bullets. Half of the blocks contained fresh calf humerus bone. The effects of the bullets in tissue simulants were monitored by using high velocity cameras capable of taking 1,000 views per second. RESULTS: On a millisecond time scale, handgun bullets produced a small-sized temporary cavity while rifle bullets produced a wide temporary cavity in isolated soft tissue simulants. It was shown that the differences in the size of temporary cavities resulting from the blast effect correlated highly with the severity of injury occurring in soft tissues. In samples at which calf humerus bone was targetted, we observed that fragmentation and cavity effects correlated highly with the velocity of the bullet and determined the severity of injury. CONCLUSION: Experimental demonstration of differences in the size and severity of injuries caused by handgun or rifle bullets may have significant implications in the planning of treatment.

Factors affecting the fracture healing in treatment of tibial shaft fractures with circular external fixator.

This study aims to analyse the contribution of various risk factors for the delay of tibial shaft fractures treated by circular external fixator and predicting the high risk fractures for delayed union. 32 extraarticular tibial shaft fractures of 31 adult patients treated with circular external fixator were included. The patients were analysed according to age, energy of trauma, having an open fracture or not, AO classification, obliquity, use of supplementary fixation techniques in surgery, distance of fracture line to neighbouring rings, having a pin-track infection or not, reduction score, and smoking. There were eight delayed unions and two non-unions in our study. Consolidation time was significantly shorter (p=0.01) between the supplementary fixation group and the others. There was a significant difference in fracture healing time between pin-track-infected patients and the patients who did not have pin-track infection (p=0.037). In conclusion, our results indicate that non-union infection and not using supplementary fixation techniques are the major factors that delay the healing time. Supplementary fixation enhances the reduction rate and a low reduction score is related with the occurrence of a pin-track infection.

Application of circular external fixator under arthroscopic control in comminuted patella fractures: technique and early results.

BACKGROUND: Comminuted fractures of the patella are traditionally treated by internal fixation. The modified tension-band technique is widely accepted for internal fixation. The management of comminuted fractures often requires additional K-wire and/or circlage material and wide surgical exposure. Therefore, symptoms and complications related to the stainless steel wire are not uncommon in these cases. We present a new alternative treatment technique for comminuted patellar fractures. METHODS: Five comminuted patellar fractures of four patients were treated by circular external fixator (CEF) under arthroscopic control. The mean patient age was 32.5 (range 24-41) years and mean follow-up was 22 (range 20-28) months. RESULTS: In four cases, union was completed by the sixth week; in the other case, union was completed by the eighth week. The frames were removed after union of the fracture was documented. When the CEF was removed, full knee range of motion was observed full in all patients, and the patients returned to their normal activities of living in a few days. The mean Lysholm score was 94 (range 85-100) after treatment. CONCLUSIONS: CEF application under arthroscopic control can help avoid some complications of the traditional treatment methods, particularly in comminuted fractures of the patella. The most important advantage of this technique is to allow active knee motion in the early postoperative period so patients can return to activity of daily living soon after the implant removal. In addition, arthroscopic examination of the knee joint provides an assessment of any other intra-articular lesions. This technique allows healing of the fracture with low morbidity.

Reconstruction of defects following bone tumor resections by distraction osteogenesis.

INTRODUCTION: The authors present the results of nine patients (two females, seven males) who had bone tumors that were treated with en bloc resection and distraction osteogenesis between 1991-2000. MATERIALS AND METHODS: The average age of the patients was 19.3 years (14-42 years). The histological diagnosis was osteosarcoma in four cases, Ewing's sarcoma in two, giant cell tumor in one, osteofibrous dysplasia in one and osteoblastoma in one. A uniplanar external fixator was applied to one case and circular external fixator to the other eight cases. RESULTS: The average follow-up period was 59.1 months (27-129 months). The external fixator was removed at an average of 18.1 months (range, 4-19 months). The average bone defect after resection was 14 cm (8-24 cm) and the average external fixation index, distraction index, and maturation index were 31.5 (18.7-40.0), 11.2 (10.9-11.2) and 17.8 (7.5-32.7), respectively. The function of the affected leg was excellent in four patients, good in three, fair in one and poor in one according to the Enneking scoring system. We did not observe any early consolidation or osseous binding in the defect area in any patient. Frequent complications were pin tract infection and non-union at the docking site. CONCLUSION: Our results indicate that the Ilizarov method allows effective restoration of bone defects in the treatment of bone tumors despite various disadvantages.