Glenoid bone loss and Hill-Sachs width percentage score are useful to select optimal operation for the treatment of glenohumeral instability in overhead athletes: Arthroscopic Bankart repair with remplissage versus open Latarjet.

PURPOSE: Glenohumeral instability with combined bone lesion in contact and overhead athletes with subcritical bone loss is challenging to treat with high recurrent instability. Treatment options are arthroscopic Bankart repair with remplissage and Latarjet operations. However, there is no consensus on their effectiveness. This study aims to compare the clinical outcomes and return to sports after both operations and whether evaluating the glenoid bone loss and Hill-Sachs width to calculate the total bone loss can help determine the appropriate operation. METHODS: In this retrospective comparative analysis, 30 athletes who underwent index arthroscopic Bankart repair with remplissage (n = 16) or Latarjet procedure (n = 14) between 2017 and 2020 were included. Computed tomography (CT) and magnetic resonance imaging (MRI) were routinely performed. The quick Disabilities of the Arm, Shoulder and Hand (qDASH), American Shoulder and Elbow Surgeons (ASES), instability severity index (ISI) scores and range of motion (ROM) were recorded preoperatively and at a mean follow-up of 53 months (SD = 12). Follow-up included time-to-return sports, self-perceived sports performance level and complications/recurrent dislocations. RESULTS: Preoperative qDASH, ASES, ISI scores, ages and genders were similar. The Latarjet group had significantly larger glenoid bone loss, Hill-Sachs width and total bone loss (p < 0.01). Both groups had significant improvement in patient-reported outcomes (PROs) after the operations (p < 0.01). Athletes with a total bone loss <25% underwent arthroscopic Bankart repair with remplissage and total bone loss ≥25% underwent Latarjet procedure, and there were no differences between the groups in terms of postoperative PROs, ROM, time-to-return sports and performance. There were no re-dislocations. CONCLUSION: Arthroscopic Bankart repair with remplissage or Latarjet procedure can adequately address glenohumeral instability with combined bone lesions. Patients with total bone loss scores greater than or equal to 25 may particularly benefit from the Latarjet procedure, while the minimally invasive arthroscopic Bankart repair with remplissage can yield equally satisfying scores for total bone loss less than 25. LEVEL OF EVIDENCE: Level III.

Effect of suprascapular nerve injury on rotator cuff enthesis.

BACKGROUND: Numerous reports have shown that retracted rotator cuff tears may cause suprascapular nerve injury, and nerve injury causes atrophy and fat accumulation in the rotator cuff muscles. However, the effect of suprascapular nerve injury on rotator cuff enthesis has not been directly defined. This study aimed to investigate the effect of suprascapular nerve injury on rotator cuff enthesis. METHODS: Twenty-four Wistar albino rats underwent bilateral transection of the suprascapular nerve. Additional 6 rats were used as the sham group. Bilateral supraspinatus and infraspinatus entheses were examined after 1, 4, 8, and 12 weeks of nerve transection. Histomorphometric analyses were performed for each zone of enthesis. RESULTS: Compared with normal enthesis, significant and consistent decrease in cellularity were observed in the tendon and bone at all time points (P < .001). Collagen bundle diameter in the tendon also decreased in a similar manner (P < .001). Apart from the tendon and bone zones, fibrocartilage and calcified fibrocartilage zones showed similar response, and significant decrease in cellularity was observed 8 weeks after nerve transection (P < .001). CONCLUSION: This study identifies suprascapular nerve injury as an underlying mechanism leading to compromise of the rotator cuff enthesis structure. Suprascapular nerve injury may be considered as an etiologic factor for the impaired healing after repair of a massive tear.

Low pH irrigation fluids have positive effect on intra-articular chondral healing.

PURPOSE: The aim of this study was to evaluate the effect of Ringer's lactate (RL) solutions with different pH values on early histologic healing in a microfracture model in vivo. The null hypothesis of the presented study is that irrigation fluids with lower pH (6.4) have negative effects on fibrous cartilage healing. METHODS: Eighteen Wistar albino rats were randomly divided into three groups. Anterior midline incision was performed. Microfracture procedure was performed with a 1.2 mm k-wire at the lateral femoral condyle of each knee. the skin was sutured and joints were irrigated for 30 min with low pH (6.4) RL in Group 1, high pH (7.6) RL in Group 2 and no irrigation in Group 3. Three rats from each group were randomly selected and killed on the 3rd and 7th day. On the 3rd day, the healed chondral area was examined. On the 3rd and 7th day, the chondral depth and morphology were evaluated. On the 7th day, bone cellularity was assessed with osteoblast; osteoclast number and bone quality were evaluated with trabecular area and the number of trabeculae. RESULTS: Chondral healing area on the 3rd day was significantly higher in Group 1 compared to other groups. Chondral morphology was also qualitatively superior in Group 1 compared to other groups on the 3rd and 7th day. There were no differences in chondral depths between the groups on the 3rd day; however, increased chondral depths were observed in Group 1 on the 7th day. There were statistically significant increases in trabecular area and the number of trabeculae, as well as the number of osteoblasts and osteoclasts in Group 1 on the 7th day. CONCLUSIONS: The presented study revealed that low pH irrigation fluids have positive effects on the healing characteristics of intra-articular fibrous cartilage after microfracture procedure in vivo. In light of this study, we can assume that lower pH solutions could be safely used during microfracture procedures and it can also facilitate intra-articular fibrous cartilage formation and cartilage healing. Selection of irrigation solution is also important for intra-articular fibrous cartilage healing after microfracture procedure in vivo.

Completion repair exhibits increased healing characteristics compared with in situ repair of partial thickness bursal rotator cuff tears.

PURPOSE: Little information is available regarding the healing capacity of in situ and completion repair for the treatment of partial thickness rotator cuff tears. The purpose of the study was to analyze the healing characteristics of both techniques. METHODS: Twenty-four adult Sprague-Dawley rats were operated. Partial thickness bursal side tears were created bilaterally at the supraspinatus tendons. Additional 6 rats were used as the sham group. The right shoulders were repaired in situ, and the left shoulders were repaired using the tear completion technique on the 10th day after detachment surgery. Rats were sacrificed on the 10th and 30th days after repair surgery. Type I collagen, the TNF-α concentrations, the number and diameter of fibroblasts, and neovascularization were examined at two different time points. RESULTS: The collagen concentration (ng/mg total protein) was significantly increased in both groups at T1 and decreased in the in situ group, whereas completion repair continued to increase at T2 (P < 0.05). The mean fibroblast diameter in the completion repair group continued to increase at both time points (P < 0.05). Neovascularization was significantly increased with tear completion compared with in situ repair (P < 0.05) at T1. No significant (n.s.) differences regarding the TNF-α concentration (pg/mg total protein) were noted for both surgical techniques at T2 (P > 0.05). CONCLUSION: Despite the concerns of detaching the intact tendon, the completion repair technique exhibited increased healing characteristics compared with the in situ technique. The reason for this finding might be the refreshing effect of debridement at the chronic degenerated tendon that could improve the healing response.

Are pelvic anatomical structures in danger during arthroscopic acetabular labral repair? Definition of safe bone depth.

PURPOSE: The purpose of this study was to evaluate safe depth for suture anchor insertion during acetabular labral repair and to determine the neighbouring structures at risk during drilling and anchor insertion. METHODS: Ten human cadaveric hips (six males and four females) were obtained. Acetabular labral surface was prepared and marked for right hips as 12, 1 and 3 o'clock positions, for left hips 12, 11 and 9 o'clock positions. Those were defined as anterior, anterior-superior and superior zones, respectively. These labral positions were drilled at defined zones. After measurements, depth of the bone at 10° and 20° drill angles on zones was compared statistically. RESULTS: Acetabular bone widths at investigated labral insertion points did not statistically differ. A total of 14 injuries in 60 penetrations occurred (23.3 %) with free drill penetrations, and no injuries occurred with stopped drill penetrations. The bone depth was gradually decreasing from 10° to 20° drill angles and from anterior to superior inserting zones without significant importance. The risk of perforation to the pelvic cavity started with 20 mm drill depth, and the mean depth for all insertions was calculated as 31.7 mm (SD 2.6). CONCLUSIONS: It is anatomically possible that some pelvic structures sustain iatrogenic injury during acetabular drilling for anchor placement. Being aware of mean pelvic vault is important in which drilling after excessive pincer rim trimming could easily decrease the depth of acetabular bone without a standard. Careful drilling by using stopped drill bit is crucial to prevent iatrogenic injury.

Palmaris longus tendon graft versus modified Weaver-Dunn procedure via dynamic button system for acromioclavicular joint reconstruction in chronic cases.

BACKGROUND: The hypothesis of this clinical study was that coracoclavicular (CC) reconstruction using autogenic palmaris longus graft through the GraftRope (PLG) system (Arthrex, Inc., Naples, FL, USA) would provide superior clinical and radiologic results compared with modified Weaver-Dunn procedure with the dynamic TightRope (Arthrex, Inc.) system (WDT). METHODS: Between 2008 and 2013, 32 patients (average age, 39.7 years; range, 22-60 years) underwent surgical reconstruction of chronic acromioclavicular (AC) joint dislocation. A modified WDT procedure was performed in 16 patients and autogenous PLG was performed in the other 16 patients. Patient data were collected retrospectively, with a final follow-up of 44.9 months (range, 29-60 months). The degree of AC joint displacement was evaluated by measuring the CC distance on the anteroposterior and axillary view. Clinical and functional outcomes were compared by American Shoulder and Elbow Surgeons and the Constant scores at final follow-up. RESULTS: Comparison between the WDT and PLG groups showed a significantly better outcome in the American Shoulder and Elbow Surgeons and the Constant scores (P < .01), in favor of the PLG group. Both groups showed an increased CC distance compared with the uninjured side, with a mean difference of 1.1 mm for the PLG and 3.3 mm for the WDT groups. A tolerable loss of reduction within the follow-up time was observed. Reduction loss was higher with the WDT group (P < .05). CONCLUSION: CC palmaris longus tendon graft reconstruction with GraftRope system was associated with functional and radiologic benefits. The palmaris longus graft with GraftRope system could be used in chronic cases.

Anatomic locking plate and coracoclavicular stabilization with suture endo-button technique is superior in the treatment of Neer Type II distal clavicle fractures.

INTRODUCTION: The purpose of this retrospective study was to compare the clinical results of three different fixation techniques for the treatment of Neer Type IIb fractures. We hypothesized that anatomic locking plate and coracoclavicular stabilization with suture endo-button technique provides more stable and biomechanically superior fixation among others with low complication rates. METHODS: Thirty six patients with Neer Type IIb fractures treated were evaluated. Patients were divided into three groups according to surgical choice that was performed: tension band and coracoclavicular suture stabilization with k-wires was defined as Group 1, anatomic locking plate and coracoclavicular stabilization with screw was defined as Group 2, and anatomic locking plate and coracoclavicular stabilization with suture endo-button (LPES) was defined as group 3. Mean age was 36.1 years, and mean follow-up period was 32.4 months. Radiological follow-ups and constant were recorded and compared at 3, 6, 12 and 24 months. RESULTS: At 3rd and 12th month follow-up in the LPES group, mean constant scores were statistically higher than other two groups (p < 0.01). The difference between other two groups was insignificant (p > 0.05). At 6th month follow-up, mean constant scores in LPES group were higher than other groups; there was less statistical significance than other time zones (p < 0.05). CONCLUSION: Anatomic locking plate combined with suture endo-button for CC ligament reinforcement is a reliable method to achieve osteosynthesis and stabilization for Neer Type IIb distal clavicle fractures without compromising physiology of shoulder.

Comparative study of the closed reduction percutaneous cannulated screw fixation and open reduction palmar locking plate fixation in the treatment of AO type A2 distal radius fractures.

INTRODUCTION: The present study was designed to demonstrate the efficacy of standard 4.0 mm cannulated screw fixation by comparing it with palmar locking plate fixation in the treatment of acute, unstable, simple extra-articular distal radius fractures. MATERIALS AND METHODS: We prospectively collected and retrospectively analyzed outcomes data for 65 patients aged between 18 and 60 with AO type A2 fractures treated with closed reduction, percutaneous cannulated screw fixation (CRPCS n = 34) or open reduction palmar locking plate fixation (ORPLP n = 31). Range of motion, grip strength, Gartland-Werley and QuickDASH scores were compared at 2 months after surgery, and final follow-up (mean 32 months, range 12-90). Deterioration in radiographic parameters were measured and compared. Operative time and return to preinjury activity were evaluated. RESULTS: Parameters did not differ significantly between the groups at either time point with respect to grip strength or range of motion, except pronation and supination; they were better in the CRPCS group (p = 0.005 and 0.025, respectively) at 2 month follow-up. The Gartland-Werley and QuickDASH scores obtained at final follow-up were similar for each group and lacked statistical significance. Group comparison for the deterioration of radiologic parameters showed no significant difference. CRPCS group had significantly shorter operative time (p = 0.001) and there was no significant differences between the groups regarding the return to preinjury activity (p = 0.129). CONCLUSIONS: CRPCS group was found to be as successful as ORPLP group and it may be suitable in the case of young, active individuals with AO type A2 distal radius fractures.

Percutaneous cannulated screw fixation in the treatment of distal radius fractures.

PURPOSE: The aim of this study was to determine the results of closed reduction and percutaneous fixation of distal radial fractures with standard 4.0-mm cannulated screw. METHODS: We collected prospective outcomes data for 20 patients between 18 and 60 years of age (mean 39) with acute, displaced, extraarticular and unstable fractures of the distal radius treated with closed reduction, percutaneous cannulated screw fixation and early mobilization. The visits at months 2, 6 and 12 were specified as index follow-up visits and assessments of motion, grip strength and standard radiographs were performed. The Gartland Werley functional scores and the Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores were recorded. RESULTS: Mean values of flexion, extension, pronation and supination on the injured side were up to 70 % of those on the uninjured side at 2 months postoperatively. By 12 months, range of motion values on the injured side showed continuous and significant improvement and flexion, extension, pronation, supination and ulnar deviation reached up to 90 % of those on the uninjured side. A large and significant improvement was seen from 2 to 6 months in the QuickDASH score. A smaller improvement was seen from 6 to 12 months, which was judged not to be significant. Radiographic values were close to anatomic parameters, and the alignment was maintained at 12 months follow-up. No complications occurred. CONCLUSIONS: Cannulated screw fixation appears to be an effective means of allowing immediate range of motion of the wrist, resulting in a rapid and comfortable functional recovery while maintaining alignment to bone healing.

Comparison of headless screws used in the treatment of proximal nonunion of scaphoid bone.

Screws with different levels of compression force are available for scaphoid fixation and it is known that the Acutrak screw generates greater compression than the Herbert screw. We retrospectively compared two types of headless compression screw for their effectiveness in the repair of scaphoid nonunion. Twenty-nine cases of proximal scaphoid nonunion were surgically treated with non-vascularised bone graft: the Acutrak screw was used in 17 patients and the cannulated Herbert screw in 12 patients. Wrist range of motion, Mayo wrist score, grip strength and QuickDASH scores were indicators used for the functional evaluation. Radiographic findings were assessed for consolidation of nonunion and signs of arthrosis. The mean follow-up time was 49.2 months (range 12-96). Statistically, there was no significant difference between the Acutrak and Herbert screw types in terms of functional evaluation and time required for consolidation. Greater compression did not influence the functional outcome, consolidation rate or time to consolidation. The need for greater compression in the treatment of proximal scaphoid nonunions is thus questionable because it may increase the risk of proximal fragment communition.

Arthroscopic inspection after the surgical treatment of patella fractures.

After the treatment of patella fractures the only way to evaluate healing at the articular surface before implant removal is through arthroscopy. The purpose of this study was to examine the healing potential of the cartilage. Arthroscopy was performed in 18 patients at the time of implant removal. The mean age of the patients was 42.1 years. The time elapsed from the index surgery to the arthroscopy and implant removal surgery was 12.9 months. During the arthroscopy, we inspected articular step-off, cartilage loss, and joint surface irregularities. Cartilage irregularities were observed in 13 of the 18 patients. Five patients had well-healed cartilage at the patellar surface. Although none of the patients had displacement at final follow-up X-rays, step-off was detected in two patients during arthroscopy. Our observation showed that cartilage lesions did not correlate with clinical and radiological evaluation. Despite good knee scores, we observed surface irregularities, chondral lesions, and fibrillation in most of the cases implicating subsequent patellofemoral arthritis.

Capitellar cartilage injuries concomitant with radial head fractures.

PURPOSE: To evaluate the incidence and types of capitellar cartilage injuries associated with higher-grade radial head fractures. METHODS: Fifty-one consecutive patients with operatively treated, unstable, displaced Mason type II to III radial head fractures were identified. Ten of 51 patients had capitellar cartilage injuries concomitant with these fractures. All cartilage injuries were identified at the time of surgery except in 1 patient whose injury was determined via computed tomography. There were 8 men and 2 women with an average age of 33 years (range, 24-39 years). Lesions were seen with direct inspection and recorded by location, size, and thickness. RESULTS: The incidence of capitellar chondral lesions concomitant with operatively treated Mason type II to III radial head fractures appeared in 10 of 51 patients. The average size was 5 x 5 mm (range, 2 x 2 mm to 10 x 10 mm). Four patients had Mason type II and 6 had Mason type III radial head fractures. The average surface of the cartilage injury was 6 x 7 mm (range, 3 x 6 mm to 10 x 10 mm) for Mason type II fractures and 4 x 4 mm (range, 2 x 2 mm to 5 x 10 mm) for Mason type III fractures. Two Mason type III fractures had full-thickness cartilage lesions, and 4 Mason type III fractures had partial-thickness cartilage lesions. Two Mason type II fractures had full-thickness cartilage lesions and the other 2 had partial-thickness cartilage lesions. CONCLUSIONS: Capitellar cartilage lesions frequently occurred concomitantly with higher-grade radial head fractures. The incidence of these lesions increased with greater severity of radial head fractures. Low-grade radial head fractures created higher-grade cartilage lesions as the intact radial head can cause more damage to the capitellum. Careful evaluation of the joint should be performed for these subtle injuries. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Incidence of chondral lesions of talar dome in ankle fracture types.

BACKGROUND: Although the surgical treatment of ankle fractures is well known, a paucity of literature exists correlating chondral lesions with ankle fracture types. MATERIALS AND METHODS: This study is a retrospective review of patients with absence or presence of chondral lesions that underwent arthroscopically assisted open reduction and internal fixation between June 2002 and April 2005. There were 38 female and 48 male patients (mean age, 41.4 years; mean followup, 33.9 months), and all had an Ankle-Hindfoot Scale score. The relationship between fracture types and presence of lesions was evaluated. RESULTS: Four of 27 fractures with chondral lesions consisted of the bimalleolar type, 6 of 15 fractures with chondral lesions consisted of the trimalleolar type, and 14 of 20 distal fibula fractures had chondral lesions. There was significant greater incidence of chondral lesions associated with distal fibula fractures. The mean AOFAS score was 95.6 among all fractures. CONCLUSION: There is clear evidence that despite anatomic reduction, postoperative results of ankle fracture repair are not free of complications. We believe inspection of the talar dome should be routinely considered in the surgical repair ankle fractures.

[Comparison between fixation with dorsal T plate and palmar locking plate in the treatment of unstable displaced distal radius fractures]. / Deplase ve instabil radius distal uç kiriklarinda dorsal T plak ile kilitli palmar plak yöntemlerinin karsilastirilmasi.

OBJECTIVES: We compared the results of fixation with dorsal T plate and palmar locking plate in the treatment of unstable displaced distal radius fractures. METHODS: Sixty-three patients (64 radii) with distal radius fractures were treated with dorsal T plate (n=41) or palmar locking plate (n=23). The mean age was 46+/-14 years (range 21 to 82 years) in the dorsal and 47+/-14 years (range 18 to 69 years) in the palmar plate groups. The fractures were classified according to the AO/ASIF system. Objective and subjective functional assessments were made using the Gartland-Werley and Quick-DASH scales, respectively. The mean follow-up was 78+/-19 months (range 12 to 101 months) and 18+/-5 months (range 12 to 28 months) with dorsal and palmar plating, respectively. RESULTS: The mean Gartland-Werley and Quick-DASH scores were 2.3+/-2.1 (range 0 to 9) and 2.0+/-2.2 (range 0 to 9) with dorsal plating, and 2.0+/-2.1 (range 0 to 6) and 1.9+/-2.7 (range 0 to 9) with palmar plating, respectively. The two groups did not differ with respect to the Gartland-Werley and Quick-DASH scores (p>0.05). Time to return to work or daily activities was also similar (1.9+/-0.3 months vs 1.8+/-0.4 months). However, patients treated with dorsal plating exhibited significantly greater values in the following parameters measured on early and late postoperative radiograms: loss of palmar tilt (p=0.001), radial height (p=0.001), radial inclination (p=0.049), and change in ulnar variance (p=0.049). Moreover, complications were seen in eight patients (19.5%) with dorsal plating, whereas no complications occurred with palmar locking plate (p=0.024). CONCLUSION: Although the two fixation methods do not differ with respect to functional results, palmar locking plating seems to provide a more rigid fixation resulting in significantly reduced collapse and a very low complication rate.

[Treatment of metacarpal fractures with open reduction and low-profile plate and screw fixation]. / Metakarp kiriklarinin açik redüksiyon ve düsük profilli plak vida sistemi ile tedavisi.

OBJECTIVES: We evaluated functional results and effectiveness of open reduction and low-profile plate fixation for the treatment of low-severity metacarpal fractures. METHODS: We retrospectively reviewed 50 metacarpal fractures of 43 patients (37 men, 6 women; mean age 31+/-9 years; range 17 to 52 years) who were treated with open reduction and low-profile plate fixation. Fractures of the first metacarpal were excluded. There were 26 oblique, 12 transverse, and 12 comminuted fractures. Three fractures were open. Objective assessment included total active motion (TARM) and grip strength. Subjective assessment was made using the Turkish version of the Quick-DASH scale. Radiographic evaluations were made on anteroposterior/lateral and oblique roentgenograms. Complications were classified as major or minor according to the Page-Stern system. The mean follow-up was 62.2+/-24.8 months (range 12 to 96 months). RESULTS: At final evaluations, the mean TARM was 220.5+/-43.9 degrees (range 30 degrees to 260 degrees ). The results were excellent in 25 patients (58.1%), good in 12 patients (27.9%), fair in five patients (11.6%), and poor in one patient (2.3%). The mean loss of grip strength was 5.2+/-7.3%. The mean Quick-DASH score was 2.0+/-2.8 (range 0 to 11). All fractures were united. Ten patients had major complications (23.2%), which included extensor tenosynovitis and plate-related discomfort requiring plate removal in four patients (9.3%), and less than 180 degrees of TARM in six patients (14%). CONCLUSION: Low-severity metacarpal fractures can be treated successfully with open reduction and low-profile plate fixation, allowing early and safe functional use.

[Surgical treatment of acute coronoid process fractures]. / Akut koronoid kiriklarinin cerrahi tedavisi.

OBJECTIVES: This study was designed to assess the results of surgical treatment for type 2-3 coronoid process fractures and to identify factors that might influence the outcome. METHODS: Thirteen male patients (mean age 35 years; range 17 to 53 years) were treated with open reduction and internal fixation for displaced coronoid fractures. According to the Regan-Morrey classification, the fractures were type 2 in nine patients (69.2%), and type 3 in four patients (30.8%). Nine patients had associated injuries (elbow dislocation, radial head or olecranon fractures, and/or ligamentous injuries). The mean duration to treatment was 2.3 days (range 1 to 7 days). Functional results were assessed according to the Mayo elbow performance score (MEPS), and signs of arthritis were assessed according to the Broberg-Morrey criteria. The mean follow-up was 41.1 months (range 12 to 96 months). RESULTS: A functional range of motion of the elbow joint was achieved in 10 patients (76.9%). The mean elbow range of motion was 110.7 degrees (range 85 degrees to 130 degrees ) and the mean forearm rotation was 134.2 degrees (range 120 degrees to 155 degrees ). Three patients who had comminuted fractures and associated elbow injuries had decreased range of motion. None of the patients exhibited signs of instability. The mean MEPS was 86.5 (range 75 to 100). The results were excellent in four patients (30.8%; the mean MEPS 98.8) having isolated or noncomminuted coronoid fractures, and good in nine patients (69.2%) with comminuted fractures and/or associated bone or ligament injuries. Post-traumatic arthritis was detected in seven patients (53.9%) whose mean MEPS was 81.4. Patients with an excellent functional result did not develop arthritis. All the patients returned to preinjury activity levels. CONCLUSION: Coronoid fractures are the most important component of complex elbow injuries. The presence of comminuted fractures, associated bone and ligament injuries, and post-traumatic arthritis affect the outcome adversely.

Complications during removal of stainless steel versus titanium nails used for intramedullary nailing of diaphyseal fractures of the tibia.

OBJECTIVES: Intramedullary nailing is the treatment of choice for fractures of the tibial shaft, which might necessitate the nail removal due to complications in the long-term. Although considered as a low-risk procedure, intramedullary nail removal is also associated with certain complications. Here, we compared the most commonly used stainless steel and titanium nails with respect to the complications during removal and clinical outcome for intramedullary nailing of diaphyseal fractures of the tibia. PATIENTS AND METHODS: Sixty-two patients (26 females, 36 males) were included in this retrospective study. Of the removed nails, 24 were of stainless steel and 38 of titanium. Preoperative and intraoperative parameters, such as implant discomfort, anterior knee pain, operating time and amount of bleeding, and postoperative outcomes were evaluated for each patient. RESULTS: Titanium nail group had more, but not statistically significant, intraoperative complications than stainless steel group during the removal of nails (p = .4498). Operating time and amount of intraoperative bleeding were significantly higher in titanium group than stainless steel group (p = .0306 and p < .001, respectively). Preoperative SF-36 physical component and KSS scores were significantly lower in patients who had removal of titanium nails than those of stainless steel nails, whereas there was no difference in terms of postoperative SF-36 and KSS scores. CONCLUSION: In conclusion, although greater bone contact with titanium increases implant stability, nail removal is more difficult, resulting in more longer surgical operation and more intraoperative bleeding. Therefore, we do not recommend titanium nail removal in asymptomatic patients.

[The effect of surgical exposure on the clinic outcomes of supracondylar humerus fractures in children]. / Cocuk suprakondiler humerus kiriklarinda cerrahi yaklasimin sonuca etkisi.

BACKGROUND: The clinic outcomes of supracondylar humerus fractures in children treated with open reduction and internal fixation by using two different surgical exposures were studied. METHODS: The clinic outcomes of seventeen and ten patients to whom lateral (LA) and posterior (PA) approaches were used respectively, were evaluated according to the Flynn's criteria. All fractures were extension type and classified as type II and III according to Gartland's classification. Left arm was broken in nineteen children and right arm in eight. The mean age was 8.5 years (range 3-13 years) and mean follow up was 19.4 months (range 8-50). RESULTS: Four (23.52%) of the seventeen patients with LA and two (20%) of the ten patients with PA suffered from a loss in the range of motion (ROM) of the elbow more than 10 degrees (p>0.05). Mean operation time was 53.14+/-18.11 minutes in the patients used LA and 68.54+/-17.67 minutes in the patients with PA. Satisfactory results were obtained in thirteen of the seventeen patients (76.47%) in the group with LA and in eight of the ten patients (80%) in the group with PA. CONCLUSION: It is concluded that in the open reduction of childhood supracondylar fractures of the humerus, LA and PA approaches without dividing triceps muscle do equally affect the ROM of the elbow. Although PA decreases the risk of ulnar nerve injury with Kirschner wire, it prolongs the operation time.

[Surgical treatment of unstable fracture-dislocations of the proximal interphalangeal joint]. / Proksimal interfalangeal eklemin instabil kirikli çikiklarinin cerrahi tedavisi.

OBJECTIVES: The purpose of this study was to evaluate the results of surgical treatment of unstable fracture-dislocations of the proximal interphalangeal (PIP) joint. METHODS: The study included 13 patients (12 males, 1 female; mean age 31 years, range 23 to 48 years) with dorsal fracture-dislocations of the PIP joint. Six patients were treated with open reduction and internal fixation using 1.2-mm titanium screws within the first week of injury. In seven patients with late presentation, time from injury to surgery ranged from 21 to 56 days (mean 37 days). Of these, one was treated with mini screws, four with bone anchors, and two with mini screws and bone anchors. The mean follow-up period was 21.5 months (range 12 to 48 months). RESULTS: Radiographic union was achieved in all the patients. The range of motion of the PIP joint was 73.4 degrees (range 50 degrees -90 degrees ) on the affected side, and 91.9 degrees (range 90 degrees -100 degrees ) on the normal side. Patients presenting early and late had significantly different range of motion of the injured fingers (84.1 degrees and 64.2 degrees , respectively; p<0.05). The mean flexion contracture of the injured fingers was 13 degrees (range 0 degrees -30 degrees ). There was no significant difference with regard to the PIP joint motion between patients treated with mini screws and soft tissue reconstruction. The mean grip strengths were 45.7 kg and 49.3 kg on the affected and normal sides, respectively. Four patients had degenerative signs in the PIP joint and one patient with late-presentation developed subluxation. Four patients complained of limitation of mild degree at work or in daily activities. CONCLUSION: Treatment of fracture-dislocations of the PIP joint yields successful results with mini screws in early cases or appropriate injuries, and with soft tissue reconstruction with or without mini screws in late-presenting patients or unfavorable injuries.

The effect of femoral nerve block on fracture healing via expressions of growth factors and ß-catenin.

INTRODUCTION: Many patients of all ages are admitted to hospital due to bone fractures. The etiology of fracture has a very wide spectrum, ranging from motor accidents to pathological conditions such as tumors, osteoporosis, and others. Bone fracture healing is a well-programmed and well-organized process, but is also long and intractable. The outcome of this process is therefore affected by many factors, such as the patient's age, ethnicity, nutritional status, and extent of the fracture. At present, regional analgesic techniques are frequently applied in order to avoid the complications of systemic opioid administration, central block applications. Femoral block is one of the regional analgesic techniques frequently applied by anesthesiologists when the lower extremities are involved. In this study, we evaluated the effect of femoral nerve block on the healing of an experimental non-stabilized femur fracture via expression of TGF-ß, VEGF, and ß-catenin and bone histomorphometry in rats. MATERIAL AND METHODS: In the control group, only the femoral fracture was performed and the bone was not fixated, similarly as in other groups. In the One-Day Block group, a one-time femoral nerve block was applied after the femoral fracture. In the Three-Day Block group, a daily femoral nerve block was performed for three days after the femoral fracture. On Days 4, 7, and 13, femurs were excised. The bone sections were stained with hematoxylin-eosin to evaluate bone tissue and Safranin O to assess callus tissue, cartilaginous tissue, and new bone areas. TGF-ß, VEGF, and ß-catenin were assessed by immunohistochemistry. RESULTS: Histomorphometric analysis revealed that femoral block application had a positive impact on bone healing. TGF-ß expression in the One-Day and Three-Day Block Groups was significantly higher than in the control group at all times, as was also the case with VEGF expression. On day 13, ß-catenin expression was significantly higher in the Three-Day Block group than the others. CONCLUSIONS: The results of the study suggests that the applications of a femoral nerve block for perioperative analgesia, for either one day or three days, resulted in better and more rapid bone healing.