The relationship between the ratio of interpedicular distance increase and the ratio of spinal canal compromise in thoracolumbar burst fractures.

BACKGROUND: The aim of the study was to investigate the relationship between the interpedicular distance increase ratio and the ratio of canal compromise in thoracolumbar burst fractures. METHODS: Thirty-one patients (18 male and 13 female) with an average age of 30.8 (14-57) who had been treated for thoraco-lumbar burst fractures in the Department of Orthopaedics and Traumatology were included in the study. The initial anteroposterior radiographs of the patients were used to calculate the increase ratio of interpedicular distance (both from medial-to-medial and from center-to-center). The area measurements from the computerized tomography or magnetic resonans images were used to calculate the canal compromise. The relationship between the increase ratio of interpedicular distance and the ratio of canal compromise was investigated by correlation and linear regression analysis. RESULTS: There was a 'very good' correlation between the from medial-to-medial and from center-to-center measurements of interpedicular distance (Pearson correlation coefficient: 0.89, p<0.001). The correlation between the ratio of canal compromise and from medial-to-medial and from center-to-center measurements of interpedicular distance was 'good' with Pearson correlation coef-ficients of 0.60 and 0.63, respectively (p<0.001). No statistically significant relationships were found between the fracture levels, types, neurologic status of the patients, and the increase ratio of interpedicular distance or the ratio of canal compromise. CONCLUSION: Depending on the correlation coefficients which were obtained in this study: To predict the canal compromise from the ratio of interpedicular distance increase is not a reliable method for all of the patients.

Anatomical variations of intercostobrachial nerve: A potential candidate for neurotization after traumatic median nerve injury?

BACKGROUND: This study focused on the anatomical characteristics and variations of intercostobrachial (ICBN) nerve and median nerve to investigate the possible use of ICBN in restoration of sensory damage of hand after traumatic median nerve injury and to evaluate the feasibility of ICBN neurotization to median nerve. METHODS: Variations of ICBN were noted in 16 axillary region dissections of eight cadavers. Measurements for ICBN's suitability in terms of neurotization to brachial plexus were done with millimetric devices. The distance of ICBN to the distal end of the lateral (LCMN) and medial (MCMN) contributions of the median nerve and the diameters of ICBN, LCMN, and MCMN were measured. RESULTS: Fifteen axillary dissections exhibited ICBN, whereas it was absent on the left side of one of the cadavers. The mean diameter of ICBN at its origin was 2.0±0.7 mm and the mean diameter of ICBN at its coaptation point was 3.1±0.9 mm. The mean diameter of the LCMN was 3.9±2.0 mm, the mean diameter of MCMN was 3.5±0.9 mm. The length of ICBN was found to be adequate at both 45 and 90° of shoulder abduction to be extended to both LCMN and MCMN. The diameters of LCMN and MCMN were not significantly correlated with the diameter of ICBN both at origin and at coaptation point (LCMN: p=0.55-0.63 and MCMN: p=0.89-0.85). There is no significant difference between the diameter of LCMN and the diameter of ICBN at its coaptation point (p=0.168) and also between the diameter of MCMN and the diameter of ICBN at its coaptation point (p=0.232). CONCLUSION: All ICBNs dissected showed adequate length to reach the lateral and medial contribution of the median nerve directly. The ICBN could be a feasible candidate since its diameter was close to LCMN and MCMN according to the descriptive and inferential statistics.

Does posterior cruciate ligament sacrifice influence dynamic balance after total knee arthroplasty? Comparison of cruciate-retaining and cruciate-substituting designs in bilaterally operated patients.

PURPOSE: This study aimed to evaluate whether the posterior cruciate ligament sacrifice during total knee arthroplasty (TKA) has any effect on postoperative standing balance or not. METHODS: The patients who underwent bilateral TKA with either CR or PS design were analyzed. 30 patients (10 PS, 20 CR) were included for the final analysis. TKA designs were compared in terms of Lysholm score, range of motion, and balance characteristics including somatosensorial, vestibular, and visual balance scales, adaptation, limits of stability, and weight-bearing/squat tests by computerized dynamic posturography. RESULTS: The mean follow-up time was 59 months for CR, 49 months for PS group. The average Lysholm score values were 94 for CR and 95 for PS group, indicating functionally similar patient groups. The average knee flexion was found significantly higher in PS group (114°) compared to CR group (102°) (p = 0.009). In the CR group, motor adaptation tests (toes up/toes down) were found to be better (p = 0.034). In the on-axis velocity parameter (linear goal orientation) of limits of stability test, PS group patients were found to be more successful (p = 0.035). CONCLUSIONS: The use of CR implants can be recommended in patients with a high risk of falling since they provide better motor adaptation providing rapid reactions to rapid surface changes. Better linear goal orientation in PS group, providing a faster movement in an intended direction, should be considered when planning the ideal implant for the patients with relevant activities.

Level of osteotomy is relevant to obtain better union and clinical results in patients with severe hip dysplasia operated on with total hip arthroplasty and shortening osteotomy using a cementless, rectangular femoral component.

INTRODUCTION AND OBJECTIVE: Total hip arthroplasty with rectangular femoral component and transverse osteotomy for patients with Crowe type 3 or 4 dysplasia yields successful results with varying radiological findings. This study aims to investigate the surgery and patient related factors associated with successful clinical and radiological results. PATIENTS AND METHODS: Fifty hips of 41 patients were retrospectively examined. Length and percentage of the stem passing the osteotomy level and canal fill ratio were measured. Radiological findings such as radiolucent lines (RL) around the stem, hypertrophic callus or an identifiable osteotomy line on X-ray images were assessed. All clinical and radiological results were analyzed for any significant association. RESULTS: Mean stem length and percentage passing the osteotomy level were 6.4 cm (± 0.7) and 51% (± 6). Presence of an identifiable osteotomy line was positively associated with the increasing length of the stem passing the osteotomy level and with a lower HHS (p < 0.05). RL around the stem were associated with a lesser reduction in VAS score (p < 0.05). CONCLUSION: Rectangular femoral stem conveniently accommodate the proximal femur in severely dysplastic hips. An upper limit for the femoral stem exists to obtain better bony union and higher HHS. RL around the stem are clinically relevant and is associated with a worse VAS score at the latest follow-up.

Clinical and Radiological Results of Crowe Type 3 or 4 Dysplasia Patients Operated on With Total Hip Arthroplasty Using a Cementless Rectangular Femoral Component Without Fixating or Grafting the Transverse Osteotomy Site.

BACKGROUND: Total hip arthroplasty (THA) involving shortening osteotomy for patients with Crowe type 3 or 4 dysplasia is a challenging surgical procedure. This study aims to demonstrate that rectangular femoral component use in anatomical reconstructions with THA and transverse shortening osteotomy yields successful results without the use of bone graft or any fixation material at the osteotomy site. METHODS: Fifty hips from 41 patients were identified retrospectively as per study objectives. All patients were evaluated using the Harris Hip Score and Visual Analog Scale for pain. Complications were reported. Radiological evaluation criteria were then evaluated, including leg length discrepancy, degree of trochanter caudalization and stem subsidence, radiolucent and radiodense lines for both components and bone atrophy or hypertrophy around the stem according to Gruen zones, and the canal fill ratio of the stem. RESULTS: Postoperative Harris Hip Score was excellent for 68% of patients. No patient had poor results. Complication rate was 32%. One patient had nonunion (2%). The mean postoperative leg length discrepancy was 0.8(±0.6) cm. No patient had a subsidence of more than 5 mm. Radiolucent and radiodense lines were present in up to 34% of patients, and bone atrophy was present in the proximal femur in up to 96% of patients. No patient had osteolysis or loosening in neither component. CONCLUSION: Successful clinical and radiological results can be obtained from Crowe type 3 and 4 dysplastic hips operated on with THA using a rectangular femoral component and transverse shortening osteotomy technique. The use of graft or any fixation material at the osteotomy site is not mandatory.

Comparison of the functional results of radial head resection and prosthesis for irreparable mason type-III fracture.

BACKGROUND: The radial head is essential for the rotational stability of the forearm and resistance to valgus stress. Radial head fractures are the most common elbow fracture in adults. Various treatment options are available, depending on the fracture severity. However, the treatment of Type-III fractures is controversial. The aim of this study was to evaluate functional results in patients with irreparable Mason Type-III radial head fractures treated with radial head resection or prosthesis. METHODS: Fourteen irreparable Mason Type-III radial head fracture patients treated with radial head resection (n=7) or radial head prosthesis (n=7) were evaluated in this multicenter, retrospective study. Disabilities of the Arm, Shoulder and Hand (DASH) and Mayo Elbow and Wrist scores were used to determine clinical outcomes. A hydraulic hand dynamometer was used to measure grip strength on the operated and unoperated sides to avoid potential bias. Measurements were made three times for each extremity, and the mean value was recorded. Grip strength was calculated as a percentage of the strength of the unoperated side. RESULTS: Functional outcomes for resection and prosthesis patients were the following: mean DASH scores, 25.8 and 17.2; mean Mayo Elbow scores, 74 and 84.1; mean Mayo Wrist scores, 84 and 92.5; and maximum grip strengths, 48.8% and 77.8%, respectively. The range of motion of the respective resection and prosthesis groups were as follows: flexion, 112.14° and 104.29°; extension, -10.00° and -25.00°; pronation, 70.00° and 47.86°; and supination, 70.00° and 52.14°. CONCLUSION: Although range of motion was restricted in the radial head resection group, functional results and grip strength were superior in patients treated with a radial head prosthesis. These results support the radial head prosthesis as a superior treatment modality for patients with irreparable Mason Type-III radial head fractures with respect to patient satisfaction and functional outcomes.

Intramedullary nail with integrated cephalocervical screws in the intertrochanteric fractures treatment: Position of screws in fracture stability.

BACKGROUND: Stable fracture fixation is important in the treatment of intertrochanteric femur (ITF) fractures in the elderly population to prevent the loss of reduction, achieve early mobility, and restore independence. The aim of this study was to present the results of surgical treatment of stable and unstable ITF fractures using a trochanteric antegrade intramedullary nail with two cephalocervical screws in an integrated mechanism (Intertan®; Smith & Nephew, Memphis, TN) and evaluate the relationship between the loss of reduction and screw position in the femoral neck in two planes. METHODS: The authors investigated all varus misalignments and losses of reduction in 57 patients (22 males, 35 females) treated for ITF fractures with the Intertan® between 2010 and 2011. Two indices (screw alignment index in the frontal projection [SAIcoronal] and screw alignment index in the lateral projection [SAIsagittal]) were defined to evaluate the loss of reduction. Patients were also evaluated according to the Harris hip score and Barthel independence index. RESULTS: The mean patient age was 77.1 years. The mean follow-up period was 21.7 months. All patients achieved complete union. We did not detect any varus collapse or loss of reduction. At the end of the follow-up period, the mean Barthel independence index was 90.7, and the mean Harris hip score was 83.7. CONCLUSION: The use of a trochanteric antegrade intramedullary nail with two cephalocervical screws allows for linear intraoperative compression and rotational stability of the head/neck fragment, prevents reduction loss, and has a wide application area in the femoral head. Its inherent continuous stability permits early weight-bearing and mobilization. It is a safe and an efficient option for the treatment of ITF fractures.

Does elasticity of Achilles tendon change after suture applications? Evaluation of repair area by acoustic radiation force impulse elastography.

BACKGROUND: Achilles tendon injuries are one of the most common tendon injuries. Surgical treatment is preferred in young and active patients. Although there are studies which evaluate the repair area with magnetic resonance imaging and ultrasonography after surgical treatment, there are very few studies which analyzes the elasticity of the tendon by quantitative methods. ARFI (acoustic radiation force impulse) elastography is a simple and non-invasive method that can quantitatively measure the elasticity of the soft tissues. Our study aims to evaluate the elasticity in the repair area of the surgically treated Achilles tendons, compare them to the non-injured side, and evaluate the effect of the suture method to the elasticity of the repaired tendons by using ARFI elastography. METHODS: In our retrospectively designed study, 19 patients who underwent surgical treatment with Krackow and modified Kessler suture methods after the Achilles tendon rupture between 2006 and 2014 were included. Shear wave velocity (SWV) of the repaired and non-injured Achilles tendons were measured by ARFI elastography in four different positions of the ankle. RESULTS: It was determined that SWV in the surgically repaired tendons were significantly higher in each four different position of the ankle, compared to the non-injured side (p < 0.01), indicating less elasticity in the repaired tendons. There was no statistically significant difference between the SWV of Krackow and modified Kessler suture method groups at four different positions of the ankle (p > 0.05). AOFAS Ankle-Hindfoot, VISA-A, VAS, and FAOS scores were not also statistically different between these two suture methods (p > 0.05). CONCLUSIONS: In the repaired Achilles tendon, there is a decrease in the elasticity compared to the non-injured side. The functional and elastographic results of Krackow and modified Kessler suture methods are similar in long-term follow-ups of the patients.

Positional alterations of the Kambin's triangle and foraminal areas in the lumbosacral region.

OBJECTIVE: The aim of this anatomical study was to compare the effects of the prone and lateral decubitus positions in endoscopic disc surgery on the Kambin's triangle (KT) and neural foramina zones in the lumbosacral region. METHODS: The study included 32 healthy volunteers (16 females and 16 males). Bilateral KT areas (KTA) and neural foraminal areas (FA) of the L4-L5 and L5-S1 levels in the prone and lateral decubitus positions were calculated depending on the freehand region of interest measurements on magnetic resonance images. KTA and FA values for each side and level in the prone and lateral decubitus positions were compared. RESULTS: Mean left KTA value in the prone and right lateral decubitus positions was 0.58 cm(2) and 0.69 cm(2), respectively, for L4-L5; and 0.69 cm(2) and 0.78 cm(2), respectively, for L5-S1 levels. Mean right KTA values in the prone and left lateral decubitus positions were 0.54 cm(2) and 0.65 cm(2) for L4-L5; and 0.69 cm(2) and 0.81 cm(2) for L5-S1, respectively. The differences in the KTA between prone and lateral decubitus positions for both levels and both sides were statistically significant (p=0.05). Only the difference in the FA between the prone and lateral decubitus positions at L5-S1 level on the right side was statistically significant (p=0.05). CONCLUSION: The KTA is wider in the lateral decubitus position than in the prone position at the levels of L4-L5 and L5-S1.

Rotational malalignment after closed intramedullary nailing of femoral shaft fractures and its influence on daily life.

BACKGROUND: Any intraoperative rotational malalignment during intramedullary nailing (IMN) of femoral shaft fractures will become permanent. We hypothesized that rotational malalignment of the femur and its compensatory biomechanics may induce problems in the hip, knee, patellofemoral and ankle joints. We purposed to clarify the influence of a femoral rotational malalignment of ≥10° on daily activities. METHODS: Twenty-four femoral shaft fracture patients treated with closed antegrade IMN were included. At last follow-up, to reveal any rotational malalignment, computerized tomography (CT) scans of both femurs (injured and uninjured sides) were examined. The patient groups with or without CT-detected true rotational malalignment ≥10° were compared with respect to the activity scores. RESULTS: Ten of the 24 patients (41.7%) had a CT-detected true rotational malalignment of ≥10° compared with the unaffected side. The AOFAS scores were 100.00 for all of the patients. LKS, WOMAC knee, and WOMAC hip scores were significantly decreased in the patients with rotational malalignment compared to those without. Patients without rotational malalignment tolerated climbing stairs significantly better than those with rotational malalignment. Patients who could not tolerate climbing stairs were consistently complaining of anterior knee pain. CONCLUSIONS: A femoral rotational malalignment of ≥10° is symptomatic for the patients, and the hip, knee, and patellofemoral joints were affected. Because of the possibly altered joint loadings and biomechanics, these could render patients prone to degenerative joint disease. In addition, due to the high rates of rotational malalignment after femoral shaft fracture and consequent malpractice claims, it is important for surgeons to be more aware of rotational alignment during surgery.

In vitro investigation of heat transfer in calf spinal cord during polymethylmethacrylate application for vertebral body reconstruction.

The objective of this experimental study was to investigate the temperature variations within the spinal cord of calf cadavers during polymethlymethacrylate (PMMA) application for vertebral body reconstruction. Cervical spines including the cervical spinal cord of ten fresh cadavers were used. Corpectomy and laminectomy were performed and dura was exposed at the same level for proper placement of thermal sensors. Sensors were placed in multiple holes in the spinal cord at depths of 3, 6, 9 and 12 mm, respectively. Whether the thermal sensors were placed in the gray or white matter was determined by computerized tomography. The white and gray matters of the spinal cord exhibited different thermal properties. The white matter was more conductive and absorbed less heat than the gray matter. The heat sensor nearest to PMMA exhibited temperatures of 42-44 degrees C. The second heat sensor placed at 9 mm depth within the gray matter showed 44 degrees C. The third sensor, which was placed at 6 mm depth within the spinal cord recorded the same temperature as the first, i.e., nearest to PMMA sensor. The fourth heat sensor, which was at the farthest location from PMMA demonstrated 37-39 degrees C. The temperature distribution within the gray matter was inversely proportional to the distance from the heat source. The temperature at the dorsal white matter, which was distant from the heating source, remained nearly constant and was not elevated. Our data suggest that thermal injury to the spinal cord during PMMA application may be expected to be more significant in the gray matter when compared with other neural tissues.

Finite element method based stress analysis of zone I and zone II sacral fractures.

BACKGROUND: Sacral bone fractures after direct traumas such as gunshot wounds and blunt sacral traumas are rarely, whereas those occurring after indirect traumas with vertical shear mechanisms ( car accidents or falls) are more frequently seen. METHODS: A cadaver sacrum was modelled 3-dimensionally using finite element software. Left sacroiliac joint was modeled to simulate a 75- kg man falling on one leg from a height of 5 meters. An impact load of 10 kN was transferred to the sacrum via intervertebral disc surface and two facets. Von Mises equivalent stress distribution was estimated. RESULTS: Von Mises stress distribution was calculated for sacral ala (430 MPa), S1 pedicle (225 MPa), and S1 lamina (35 MPa). Stress values were 200 Mpa, 130 Mpa, 105 Mpa, and 55 MPa on ventrolateral, dorsomedial, ventromedial and dorsolateral sides of S1 foramen respectively. Vertical shear injury caused stress distribution to concentrate at sacral ala and S1 pedicle (zone I). Local stress distribution around S1 foramen is concentrated ventrolaterally CONCLUSION: High incidence of zone I sacral fractures and low incidence of neurological deficits could be explained by concentration of stress at sacral ala. Zone II fractures might be due to by transfer of triggered stresses from sacral ala and S1 pedicle to ventrolateral side of S1 foramen.

Effect of decortication on laminar strength during sublaminar wiring: an experimental study.

Eighty lumbar segments from 16 female sheep were used to investigate the effect of laminar decortication on the strength of the lamina during sublaminar wiring procedure. Sheep were 12-14 months old. Forty vertebrae from eight animals were decorticated before loading with sublaminar wire to failure, and 40 vertebrae from the remaining eight sheep were tested with the same procedure but intact. The effects of bone mineral density (BMD) and laminar dimensions on laminar strength in both decorticated and nondecorticated groups were also investigated. The failure force values of the laminae for decorticated and nondecorticated groups were 881.15 +/- 36.86 and 298.48 +/- 21.99 N, respectively (P < 0.001). There was a positive linear relationship between BMD and laminar strength in an intact lamina. In a decorticated lamina, no significant relationship existed between these variables. There was a negative linear relationship between mediolateral length of hemilamina and laminar strength in both intact and decorticated vertebra. Laminar strength after decortication was positively related to dorsoventral length of the remaining portion of the lamina. Decortication leads to a statistically significant decrease in laminar strength.

The deep infrapatellar bursa: prevalence and morphology on routine magnetic resonance imaging of the knee.

OBJECTIVE: To evaluate the presence, location, and dimensions of the deep infrapatellar bursa on routine magnetic resonance (MR) imaging of the knee. METHODS: The study group consisted of 213 knees in 204 consecutive individuals who had undergone routine MR imaging examination of the knee within a 365-day period. Magnetic resonance examinations consisted of T1-, proton-density-, and T2-weighted sagittal; spectral presaturation inversion recovery coronal; and T2*-weighted transverse sequences. Exclusion criteria were previous knee arthroscopy or surgery or the presence of a mass lesion infiltrating the infrapatellar fat pad. The presence, location, and dimensions of the deep infrapatellar bursa were studied. The bursa was also analyzed with regard to knee joint synovial effusion (absent, mild, or marked). RESULTS: The deep infrapatellar bursa was detected in 68% of the knees, most commonly on the lateral paramedian sagittal MR images. There was no statistically significant difference between male and female subjects or between the knee sides with regard to the detection of the deep infrapatellar bursa (P > 0.05). No correlation was found between synovial effusion and the presence of the deep infrapatellar bursa. The mean anteroposterior and craniocaudal dimensions of the deep infrapatellar bursa on sagittal T2-weighted MR images were 2.1-2.7 mm and 7.3-9.1 mm, respectively, on its lateral, central, or medial location within the sagittal MR image stack. CONCLUSION: An awareness of the dimensions and location of the deep infrapatellar bursa is important in distinguishing it from pathologic lesions (eg, bursitis).

Calcification of the patellar tendon after ACL reconstruction. A case report with long-term follow-up.

Extensive calcification of the patellar tendon following ACL reconstruction with central-third bone-patellar tendon-bone autograft is a rarely seen complication. A 45-year-old male patient underwent combined intraarticular reconstruction of ACL with 1/3 central patellar bone-tendon-bone graft and extraarticular reconstruction with modified MacIntosh technique. Two cm of calcification of the patellar tendon was observed incidentally when he underwent a high tibial osteotomy due to medial compartment degeneration, secondary to varus malalignment, 18 months after the ACL surgery. The calcification, being painless, was left untouched during the surgery. At the final examination, 136 months postoperatively, the patient still had no complaint relating to the patellar tendon.