Greater tuberosity medial malposition: does it affect shoulder abductor moment?

PURPOSE: The detrimental effect of greater tuberosity malposition on functional scores is well known. Superior or posterior malpositions exceeding five mm lead to excessive loading on the deltoid strength. However, the significance of situations where greater tuberosity becomes medialized due to the compressive effect of the locking plate fixation, especially in fractures with metaphyseal dead space, has not been emphasized. It is hypothesized that this condition may cause shortening of the rotator cuff moment arm and consequently impact functional scores. METHODS: Between 2012 and 2018, 52 patients, aged 65,28 (ranging 40-85) proximal humerus fractures treated with locking plate fixation were included in the study. Cephalodiaphyseal angle, greater tuberosity displacement , patients reported outcome and Constant-Murley scores were evaluated. RESULTS: The mean Constant Murley score was determined to be 78.76 (ranging from 38 to 100). According to the patients reported outcome 39 excellent , five good , two fair, six poor results were observed. Avascular necrosis with screw migration was detected in five cases, while one patient experienced implant insufficiency along with varus deformity. Greater tuberosity was found to be positioned between 6 mm posterior-superior and -13 mm medial. Significant medial malposition was observed in three patients, with -9, -12, and -13 mm of medialization, respectively. Cephalodiaphysial angle was determined as 139.30 degrees (ranging from 120 to 150 degrees) and showed weak correlation with the functional score. Greater tuberosity medialization also showed weak correlation with the Constant-Murley score. The values exhibiting deviation were associated with low patient-reported outcome results and functional scores. In the examination of greater tuberosity displacement values, it was observed that Neer type 3 and 4 fractures differed significantly from Neer type 2 fractures regarding to Kruskal-Wallis test. CONCLUSIONS: Medial impaction of greater tuberosity may be the reason of decreased functional scores, similar to superior or posterior malposition. The medialization of greater tuberosity should be considered as a potential factor leading to the shortening of the rotator cuff's abductor moment.

Posteromedial plate application using medial midline incision for complex tibia plateau fractures: a retrospective study.

BACKGROUND: Application of a posterior plate for tibia plateau fractures associated with posterior column involvement is becoming a widespread standard practice as previous studies have shown that additional fixation of the posterior column with a posteromedial buttress plate creates strongest fixation in terms of fracture stabilization This study evaluated the clinical and radiological results of patients undergoing surgery for complex tibial plateau fractures involving the posterior column with a posteromedial plate applied via a medial midline incision. METHODS: Medical records of patients undergoing surgery for Schatzker type IV, V, and VI tibia plateau fractures involving the posterior column in our institution were reviewed retrospectively. Patients with a follow-up of less than 1 year, pathological fractures, posterolateral column fractures requiring separate fixation, and open fractures were excluded from the study. Three-dimensional computed tomography (3D CT) was performed in all patients before surgery. The study population consisted of 25 patients (21 males and 4 females) with a mean age of 41.5 (19-66) years. The etiologies of the fractures were traffic accidents in seven cases, pedestrian falls in five cases, falls from a height in seven cases, and motor vehicle accidents in six cases. RESULTS: The mean follow-up period was 15.9 months (12-25), mean time to union was 14.32 (9-20) weeks, mean Knee Society score (KSS) was 88 (81-95), and range of movement (ROM) was 123° (95°-140°). Loss of reduction was detected in only one patient (4%). A superficial incisional infection occurred in an anterolateral incision in only one patient (4%), and it recovered after oral antibiotic therapy. None of the patients required early implant removal and none had vascular or nerve complications in the postoperative period. Postoperatively, 23 (92%) patients had anatomical reduction and 2 (8%) had acceptable reduction in the sagittal plane CT sections. Acceptable reduction was achieved in 6(24%) patients and anatomical reduction was achieved in 19 (76%) in the coronal plane CT sections (Table 2). CONCLUSIONS: Clinical results of posteromedial plate application using a single medial midline incision is promising as complication rates were very low and knee scores were high.

Is There a Chance to Treat Modified Gartland Type IIB Pediatric Supracondylar Humerus Fractures With Closed Reduction and Casting?

BACKGROUND: Wilkins modification of the Gartland classification (WMGC) type IIB supracondylar humeral fractures (SCHFs) are unstable, and their primary treatment is surgery. This study sought to evaluate the chance of closed reduction and long arm cast (CR&LAC) treatment of type IIB fractures. METHODS: In this retrospective case-control study, pediatric patients with WMGC type II fractures whose initial treatment was CR&LAC were examined. Cases were subdivided according to WMGC. Type IIA and IIB cases were compared in terms of the reduction loss rate and clinical and radiologic results. Then, patients with type IIB fractures who were treated conservatively or surgically were compared in terms of clinical and radiologic results. RESULTS: A total of 817 pediatric SCHFs were examined, of which 233 had type II fractures. This study finally enrolled 87 cases who met the inclusion criteria, including 52 with type IIA fractures and 35 with type IIB fractures. Among those with type IIB fractures, the first-time reduction success rate was 44.3%. Although the probability of a loss of reduction among type IIB fractures in conservative follow-up was ~5 times higher than that among type IIA fractures, all the cases with reduction loss were detected among the first-week controls, and 9 of them were type IIB and 3 were type IIA ( P =0.011). The treatment of 26 (32.9%) cases with type IIB fractures was completed conservatively. There was no difference in the clinical or radiologic comparison results of type IIA and type IIB fractures whose treatment was completed conservatively. There was no clinical or radiologic difference in the comparison of type IIB fractures whose treatment began with CR&LAC but was completed conservatively or surgically. CONCLUSIONS: Although the initial reduction success is not high among WMGC type IIB fractures, the results are like those of conservatively managed type IIA fractures if successful reduction is achieved. This study showed that the treatment results of all type II SCHFs with no loss of reduction in the first week after CR&LAC are satisfactory. No reduction loss was observed in any of the cases after the first week. LEVEL OF EVIDENCE: Level III, case-control study.

Arthroscopically assisted acromioclavicular joint stabilization leads to significant clavicular tunnel widening in the early post-operative period.

PURPOSE: Arthroscopically assisted acromioclavicular joint (ACJ) stabilization techniques use bone tunnels in the clavicle and coracoid process. The tunnel size has been shown to have an impact on the fracture risk of clavicle and coracoid. The aim of the present study was to radiographically evaluate the alterations of the clavicular tunnel size in the early post-operative period. It was hypothesized that there would be a significant increase of tunnel size. METHODS: Twenty consecutive patients with acute high-grade ACJ (Rockwood type IV-V) injury underwent arthroscopic-assisted ACJ stabilization. The median age of the patients was 40 (26-66) years. For all patients, a single tunnel button-tape construct was used along with an additional ACJ tape cerclage. Radiologic measurements were undertaken on standardized Zanca films at two separate time points, immediate post-operative examination (IPO) and at late post-operative examination (> 4 months; LPO). The LPO radiographs were taken at a median follow-up period of 4.5 (3-6) months. Clavicular tunnel width (CT) and coracoclavicular distance (CCD) were measured using digital calipers by two independent examiners and the results are presented as median, range, and percentage. RESULTS: The median CCD increased significantly from 9.5 (8-13) mm at IPO to 12 (7-20) mm at LPO (p < 0.05). Median tunnel size showed significant difference from 3 (3-4) mm at IPO to 5 (4-7) mm at LPO (p < 0.05). Despite a significant increase of 2 mm (66.6%) of the initial tunnel size, there was no correlation between tunnel widening and loss of reduction. CONCLUSION: Arthroscopic ACJ stabilization with the use of bone tunnels led to a significant increase of clavicular tunnel size in the early post-operative period. This phenomenon carries a higher fracture risk, especially in high-impact athletes, which needs to be considered preoperatively. LEVEL OF EVIDENCE: IV.

Subgroups and differences of fixation in 3-part proximal humerus fractures.

BACKGROUND: This study aimed to determine the morphological differences of three-part proximal humerus fractures, the group in which plate screw fixation is most frequently used, and to evaluate the functional and radiological results of the methods applied for different subgroups. METHODS: Twenty-nine patients (6 males and 23 females) with three-part proximal humerus fractures were in the study, with an average age of 64. The patients were in three groups according to their fracture types. Group 1 included eight patients with valgus impaction fracture. Group 2 included eleven patients with easily achieved stability after reduction. Group 3 consisted of ten patients with procurvatum varus angulation, a significant displacement between fragments, and in whom medial cortical continuity was not maintained without fixation. All patients underwent surgery with a minimally invasive deltoid split approach method and locked ana-tomic plate screw osteosynthesis. In group 1 patients, the space in the area where valgization is present in the head was filled with cortico-cancellous allografts. No grafting or metaphyseal compression took place in Group 2 patients. In group 3 patients, the metaphyseal compression technique was applied to the bone defect area. Cephalodiaphyseal angles (CDA) were measured at the postoperative and final follow-up. The constant Murley score made the functional evaluation. RESULTS: The patients were followed for an average of 27.6 months, and the union was present in all patients for an average of 3.6 months. Early screw migration was present in three patients, and late screw migration was in one patient. There were twenty-four excellent and 5 good results. CDA decreased from 139.42° to 136.13°. A statistically significant difference was present between the values of Groups 2 and 3 in the final control CDA of the groups. CONCLUSION: In this study, the functional scores of grafting stable valgus-impacted fractures and metaphyseal compression of unstable fractures with insufficient medial support were as good as stable 3-part fractures. Considering neer type 3 fractures should be evaluated with their subgroups, and fixation and stability-enhancing solutions specific to the groups are essential.

A cross-sectional study on reliability and quality of YouTube® videos related to hallux valgus and evaluation of newly developed hallux valgus-specific survey tool.

Objective: Previous studies have reported low quality and reliability on YouTube videos about various medical issues including videos related to hallux valgus (HV) treatment. Therefore, we aimed to evaluate the reliability and quality of YouTube videos on HV and develop a new HV-specific survey tool that physicians, surgeons, and the medical industry can use to create high-quality videos. Methods: Videos viewed over 10,000 times were included in the study. We used the Journal of the American Medical Association (JAMA) benchmark criteria, global quality score (GQS), DISCERN tool, and new HV-specific survey criteria (HVSSC) developed by us to evaluate the quality, educational utility and reliability of the videos, the popularity of which was assessed using the Video Power Index (VPI) and view ratio (VR). Results: Fifty-two videos were included in this study. Fifteen videos (28.8%) were posted by medical companies producing surgical implants and orthopedic products, 20 (38.5%) by nonsurgical physicians, and 16 (30.8%) by surgeons. The HVSSC indicated that the quality, educational value, and reliability of only 5 (9.6%) videos were adequate. Videos posted by physicians and surgeons tended to be more popular (p = 0.047 and 0.043). Although no correlation was detected among the DISCERN, JAMA, and GQS scores, or between the VR and VPI, we found correlations of the HVSSC score with the number of views and the VR (p = 0.374 and p = 0.006, respectively). A good correlation was detected among the DISCERN, GQS, and HVSSC classifications (rho = 0.770, 0.853, and 0.831, respectively, p = 0.001). Conclusions: The reliability of HV-related videos on YouTube is low for professionals and patients. The HVSSC can be used to evaluate the quality, educational value, and reliability of videos.

Comparison of intramedullary nail and plate osteosynthesis in humerus surgical neck fracture.

BACKGROUND: The aim of this study is to compare clinically and radiologically the plate osteosynthesis method and the in-tramedullary nail (IMN) method, which is currently used in the surgical treatment of surgical neck proximal humerus fractures (PHFs) in which there is no consensus METHODS: A total of 248 patients who underwent PHF between January 2013 and December 2017 were retrospectively reviewed. Sixty-two patients were included in the study. The results were clinically compared in terms of the amount of blood loss, operative time, and union time. Radiologically, it was compared in terms of intraoperative neck-shaft angle (NSA), final NSA, the American Shoulder and Elbow Surgeons (ASES), and Constant and Visual Analog Scale (VAS) scores. RESULTS: Two groups were formed: plate and IMN. The groups were similar in terms of age, sex, operation side, and follow-up time. There was no difference between the groups in terms of NSA, final NSA, ASES, Constant, and VAS scores. The amount of intraoper-ative blood loss, operative time, and union time was shorter in the IMN group. CONCLUSION: In surgical neck PHF surgery, plate and IMN are methods that show good clinical outcomes. According to this study, the advantages of the IMN method compared with plate osteosynthesis in Neer type II PHF treatment can be listed as less intraoper-ative blood loss, shorter operative time, and union time.

Comparison of clinical and radiological results after a minimum one-year follow-up of tibial fractures operated via suprapatellar or infrapatellar intramedullary nailing: A retrospective study.

OBJECTIVES: In this study, we aimed to evaluate the clinical and radiological results after a minimum one-year follow-up of suprapatellar (SP) and infrapatellar (IP) nail applications for the treatment of tibial fractures. PATIENTS AND METHODS: Between September 2019 and September 2021, a total of 80 patients treated for tibial fractures were retrospectively analyzed. The patients were divided into two equal groups including 40 patients in each group. The first group (32 males, 8 females; mean age: 36.4±13.2 years; range, 19 to 64 years) consisted of those who were operated using intramedullary nailing (IMN) through the SP approach (SP group). The second group (25 males, 15 females; mean age: 34.4±13.6 years; range, 15 to 64 years) consisted of patients operated with IMN using an IP approach (IP group). Data including the location of the fracture, duration of surgery, need for additional interventions for fracture reduction, union time, duration of follow-up, delayed union, nonunion, malunion, and infection rates were recorded. During the final follow-up, we evaluated the results for range of motion (ROM), Visual Analog Scale (VAS), score, Lysholm score, and Knee Society Score (KSS) postoperative functional outcome measure. RESULTS: The mean duration of follow-up in the SP and IP groups were 17.6±2.3 (range, 13 to 21) and 19.9±1.3 (range, 15 to 41) months, respectively (p=0.236). The mean duration of surgery was significantly shorter in the SP group than in the IP group (73.2±19.9 [45 to 160] min in the SP group and 152.0±28.5 [100 to 240] min in the IP group) (p=0.0001). There was no significant difference between the groups regarding duration of postoperative hospital stay, union time, and decrease in hemoglobin levels. There was no significant difference between the groups regarding Lysholm scores, KSS functional outcome scores, VAS, ROM, and thigh and calf diameter difference measured at the final follow-up. A Poller screw or provisional Kirschner wire was used for 14 (35%) of 16 diametaphyseal fractures in the IP group. No additional technique was used for any patient in SP group (p=0.001). CONCLUSION: The SP application of an IMN for diaphyseal tibial fractures yields an easy and practical application, having easy reduction with shorter operative time and no need for additional techniques to achieve reduction. However, the clinical and radiological outcomes of both techniques are similar after a one-year follow-up.

A simple minimally invasive technique providing anterior and medial reduction in intertrochanteric femur fractures: A case-control study.

BACKGROUND: The aim of the study was to compare the clinical and radiological results of the Verbrugge minimally invasive technique used in AO/OTA 31-A2.2/A2.3 intertrochanteric fracture types with those of the closed reduction technique performed on a traction table. METHODS: A retrospective evaluation was made of 671 patients treated in our clinic for intertrochanteric fracture between 2017 and 2020. The patients included in the study were those aged >70 years, applied with intramedullary nailing for an AO/OTA 31-A2.2/A2.3 fracture type, with >1 year of follow-up. Patients were excluded if they did not meet these criteria, if they had a pathological fracture, an open fracture, or a history of hip surgery. A total of 177 patients were accepted for analysis in the study. The patients were separated into two groups as those where reduction was provided with the Verbrugge minimal invasive technique Verbrugge reduction group (VRG) and those with closed reduction applied on a traction table Conventional reduction group (CRG). The reduction quality was evaluated radiologically with the modified Chang method and the varus reduction rates were compared. The clinical results of the groups were compared in respect of time to full weight-bearing mobilization, complication rates, and Harris Hip Scores (HHS). RESULTS: Varus malreduction was seen less often in the VRG compared to the CRG, the reduction quality was more successful, the patients could be mobilized earlier and the HHSs were better. No significant difference was determined in terms of operating time and complications. CONCLUSION: The Verbrugge method can be used in all AO/OTA 31-A2.2/A2.3 intertrochanteric fractures where closed reduction applied on a traction table is not sufficient. This method can be considered to be an effective technique that increases the quality of the fracture reduction, provides protection throughout the operation, and has similar complication rates to those of the conventional reduction method.

Risk factors for cut-out in intertrochanteric fractures treated with proximal femoral nail of double proximal screw design.

Background: Intertrochanteric femoral fractures (IFF) are often seen in the elderly after a simple fall because of osteoporosis, and treatment is generally provided with proximal femoral nail (PFN). The complication of cut-out, which can develop as a result of PFN treatment of IFF, is a significant cause of morbidity. The aim of this study was to examine the risk factors for cut-out in cases treated with double proximal screw design nail (DPSDN). Methods: A retrospective examination was made of patients aged> 70 years, who were operated on for IFF using DPSDN between January 2018 and December 2020. A record was made of the potential risk factors of age, gender, osteoporosis level (Singh Osteoporosis Index), fracture classification (AO/OTA classification), reduction quality, tip-apex distance(calTAD), and proximal screw placement values. Using logistic regression analysis, it was attempted to determine predictive factors for cut-out complication in cases operated on with DPSDN. Results: With 219 cases included in the study, two groups were formed as cut-out and non-cut-out. Reduction quality, calTAD, and proximal screw placement were seen to be risk factors for cut-out. According to the univariate logistic regression analysis, the cut-out risk was 57.917-fold greater in those with "poor" reduction quality compared to those with "good" reduction quality, the risk was 17-fold greater in those with "superior"screw placement compared to "central" placement (p < 0.001), and 9.24-fold greater in those with "anterior" placement compared to "central" placement (p < 0.001). The cutoff value for calTAD for the diagnosis of cut-out was found to be > 25.5 mm (p = 0.026). Conclusion: The results of this study demonstrated that the most important risk factors in the use of DPSDN are reduction quality, calTAD and proximal screw placement,. It was also concluded that just as in implants designed with a single screw, there is an increased risk when calTAD is > 25 mm.

A minimally invasive fixation technique for selected patients with fifth metacarpal neck fracture.

OBJECTIVE: The objective of this study was to compare the short-term results of treatment of fifth metacarpal neck fractures using a minimally invasive surgical fixation technique and the gold standard splinting method in a selected patient group of office workers with high expectations. PATIENTS AND METHODS: Twenty-four male patients (mean age: 28 years, range: 18-46 years) satisfying the inclusion criteria were enrolled in the study in two groups: surgical treatment and splinting (U-shaped ulnar gutter) groups. Hygienic interactions during daily activities and the use of keyboard and pens were allowed in the posttreatment period. The Short Form-Disabilities of the Arm, Shoulder and Hand Score (DASH) questionnaire was used to assess patient satisfaction and functionality of the extremity on the 30th and 45th days. Joint ranges of motion were measured on the 45th day. Functional and radiological evaluation data were analyzed statistically. RESULTS: In the conservative treatment group, initial palmar angulation was measured to be 42.6°, whereas a mean of 13.5° was noted and metacarpal shortening of 5.6mm decreased to 2mm after treatment, respectively. In terms of total joint range of motion (ROM), flexion of the treated side was at 91.25% and extension at 92.5% when measured versus the healthy-side values at the final follow-up. The mean time for return to work in this group was 33.6 days. The mean Quick-DASH score on the 30th-day follow-up was 69.5, whereas it was 39.3 at the 45th-day follow-up. The radiological findings showed a correction of the mean palmar angulation from 43° to 8° at follow-up in the surgically treated group. The initial metacarpal shortening of 9.3mm improved to 0.5mm at final examination. In terms of total joint ROM, flexion of the treated side was at 94% and extension at 95.5% when measured versus the healthy-side values on the 45th-day follow-ups. The mean time for return to work was 3.9 days. The mean Quick-DASH score on the 30th-day follow-up was 2.96, whereas it was noted as 0.69 at the 45th-day follow-up. CONCLUSIONS: We recommend antegrade intramedullary K-wire fixation as a reliable method, which minimizes the functional loss and allows for early return to daily activities in office workers who sustained a fracture of the fifth metacarpal neck.

Functional outcomes of repair of Achilles tendon using a biological open surgical method.

OBJECTIVE: The aim of this study was to evaluate the mid-term functional outcomes of ankles following biological open Achilles tendon repair and early postoperative mobilization. METHODS: The study retrospectively evaluated 22 male patients who underwent one-sided biological open Achilles tendon repair. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, isokinetic muscle strength and endurance tests and active angle reproduction test at 15° of dorsiflexion and 20° of plantarflexion of the injured and uninjured sides were measured and compared. RESULTS: Mean age was 38.6 years and mean follow-up was 33.7 months. One patient had rerupture following a blunt trauma 1 month after operation. No other complication was seen. Mean AOFAS hindfoot score was 97.9 (range: 90 to 100). Peak isokinetic torque at 30°/sec (isokinetic muscle strength) and total work at 120°/sec (isokinetic muscle endurance) did not significantly differ between the operated and uninjured ankles. Proprioceptive evaluation with active angle reproduction test at 15°of dorsiflexion and 20° of plantarflexion was similar between the two sides. CONCLUSION: Biological open Achilles tendon repair with early postoperative mobilization appears to be a convenient intervention for acute Achilles tendon rupture in active young patients. Treatment results in low complication rates and restores ankle strength, endurance and position sense.

Mid-term results of Oxford Phase 3 unicompartmental knee arthroplasty in obese patients.

OBJECTIVE: The aim of this study was to evaluate the mid-term outcomes of Oxford Phase 3 unicompartmental knee arthroplasty (UKA) in obese patients in terms of prosthesis survival, progression of lateral compartment arthrosis and functional outcomes. METHODS: The study included 67 patients, with a body mass index over 30, treated with mobile bearing Oxford Phase 3 UKA for isolated medial osteoarthritis between January 2005 and December 2010. Preoperative and postoperative knee range of motion (ROM) and knee scores (Hospital for Special Surgery, HSS and Oxford knee scores) were compared. Additionally, prostheses were evaluated using Oxford radiographic evaluation criteria at the final follow-up. RESULTS: Mean age was 61 years and mean follow-up was 67.5 months. Insert dislocation occurred in 3 patients (4.5%). Postoperative knee ROM, HSS and Oxford knee scores were significantly improved (p<0.05). There was no sign of prosthesis failure or lateral compartment arthrosis in radiographic evaluation at the final follow-up. CONCLUSION: Oxford Phase 3 UKA with mobile bearing has good mid-term results in obese patients over 60 years of age.