Ilizarov segmental bone transport of infected tibial nonunions requiring extensive debridement with an average distraction length of 9,5 centimetres. Is it safe?

OBJECTIVES: To evaluate the results of one stage radical debridement and segmental bone transport with circular fixator in the treatment of infected tibial non-union requiring extensive debridement with an average defect size of 8 cm and distraction length of 9,5 cm. DESIGN: Retrospective study. SETTING: Level I trauma centre at an academic university hospital. PATIENTS: Thirty patients with infected tibial non-union with an average of 2,9 previous failed operations after a mean 12,5 months post-injury were treated consecutively. The mean age was 39,5 years (R:16-68). After radical debridement and irrigation, all patients were treated with segmental bone transport using Ilizarov circular fixator. All patients except 3, managed with an open docking protocol without bone grafting. In 2 patients a planned ankle arthrodesis with transport was done. MAIN OUTCOME MEASUREMENTS: Bone union, resolution of infection, external fixation index (EFI), external fixation time (EFT), bone and functional results for this big defect size. RESULTS: Union and eradication of infection was achieved in all patients. Mean follow-up was 32,5 months (R: 12-72 mo.) The average bone defect after debridement was measured 8.1 cm (R, 6-15). The total distraction length to restore the debridement defect and previous LLD was 9,5 cm (R, 6-15). The mean external fixation time was 13,7 months; the mean external fixation index was 1,49 mo./cm. One non-union, one refracture and one late valgus deformity was managed successfully with plating or nailing and all were healed uneventfully at the completion of the treatment. According to Paley & Maar and Katsenis criteria, the bone results were excellent in 24 and good in 6, functional scores were excellent in 21, good in 7, and fair in 2 patients. Minor complications were 1,36 per patient, major complications were 0,4 per patient and permanent complications were 0,2 per patient in the study group. CONCLUSION: In the management of large post-infectious bone defects requiring an average 9,5 cm distraction; segmental bone transport is safe in terms of union and eradication of infection. The EFI, EFT, complications, bone and functional results do not differ from the other published studies with smaller defect size.

Comparison of operating time, fluoroscopy exposure time, and functional and radiological results of two surgical methods for distal forearm fractures of both-bones in pediatric patients: Is it necessary to fix both bones?

OBJECTIVE: The aim of this study was to compare the functional results of internal fixation of both forearm bones versus fixation of the radius alone in the treatment of distal both-bone forearm fractures in children. METHODS: This study included a total of 34 children who were treated for distal forearm both-bone fracture. Patients were divided into two groups according to the technique used, which depended on the date of their surgery. Group 1 consisted of 18 children (14 males and four females; mean age: 10.3 years; age range: 7-16 years) who underwent both-bone fracture fixation using closed reduction and percutaneous pinning; Group 2 consisted of 16 children (12 males and four females; mean age: 10.1 years; age range: 6-15 years) who underwent only radius fracture fixation. The average follow-up was 65.6 months in Group 1 and 38.9 months in Group 2. Operating time, fluoroscopy exposure time, functional results (Mayo Wrist Score, visual analogue scale score, and range of motion), radiological results (time to union and malunion), and complications were recorded as outcome parameters. RESULTS: The mean operating time was 35 min (range: 30-45 min) in Group 1 and 19 min (range: 10-25 min) in Group 2 (p<0.001). The mean fluoroscopy exposure time was 54 sec (range: 40-70 sec) in Group 1 and 18 sec (range: 10-26 sec) in Group 2 (p<0.001). Only three patients in Group 1 and four patients in Group 2 exhibited <10° of limitation in pronation and supination. No significant differences were determined between the groups with respect to functional scores (p=1.000). Final follow-up radiographs showed no malalignment in either group. In terms of time to union, there was no significant difference between groups (p=1.000). Additionally, only three minor complications associated with the pin track (two patients in Group 1 and one patient in Group 2) were noted. CONCLUSION: In children with distal both-bone fractures, fixation of the radius fracture alone may be considered as an alternative method of treatment to fixation of both forearm bones as it results in satisfactory functional and radiographic outcomes. LEVEL OF EVIDENCE: Level III, Therapeutic study.

Improved Gait Parameters After Orthotic Treatment in Children with Infantile Tibia Vara.

The aim of this study was to investigate the modification of gait kinematics before and after orthotic treatment in patients with ITV. Vicon instrumented gait analysis was performed on three patients with ITV, pre and post treatment. Orthoses were applied a total of eighteen participants with ITV who were 25-38 months. 34 extremities were treated and radiographic evidence evaluated before and after orthotic treatment. Treatment duration for orthotic treatment ranged between 11 and 41 (25.9 ± 10.0) months. Only three patients were evaluated in gait analysis due to application difficulties. Three patients kinematic and kinetic instrumented gait analysis were found flatfoot, varus and internal rotation of the foot, hip flexion and external rotation. Study were reported an improvement in gait kinematics after orthotic treatment, in patients with ITV.

Do the Loss of Thigh Muscle Strength and Tibial Malrotation Cause Anterior Knee Pain after Tibia Intramedullary Nailing?

PURPOSE: Anterior knee pain (AKP) is a common complication after tibia intramedullary nailing surgery, but yet the etiology is not fully revealed. Our study had two hypotheses. The first one is "after tibia intramedullary nailing with transtendinous approach, thigh muscles strength decreases and this loss of muscle strength causes AKP." Secondly, "lower extremity rotational profile is affected after tibia intramedullary nailing." Methods. Our study was planned retrospectively and included 40 patients, who underwent tibia intramedullary nailing surgery. Mean follow-up time was 22.5 months. Tegner Lysholm knee scoring scale was applied to evaluate postoperative functional outcomes of all patients. Isometric muscle strengths of bilateral knee extensor and flexor muscle groups were compared with hand-held dynamometer. In addition, bilateral lower extremity Staheli rotational profile angles (foot progression angle (FPA), thigh-foot angle (TFA), and transmalleolar angle (TMA)) were compared. RESULTS: Lysholm knee score was evaluated as excellent in 28 patients. AKP were detected in 15 patients and there was no significant difference between the injured limb with contralateral quadriceps mean muscle strength (injured limb mean (ILM) = 201.97 Newton (N) - contralateral mean (CM) = 205.4 N). However, there was a significant difference (p<0,05) between injured limb with contralateral extremity hamstring mean muscle strength (ILM = 153.2 N- CM=158.95 N). Although there was a significant difference between the two extremities' rotational profile angles, there was no significant correlation between the rotational profile angles and knee pain. CONCLUSION: As a result of our study, AKP appears to be significantly related to the loss of hamstring muscle strength. We suppose that hamstring exercises will gain importance in rehabilitation programs of tibia intramedullary nailing surgery in future.

Comparison of three posterior malleolar fixation methods in trimalleolar ankle fractures.

This study aimed to compare the results of AP screws, PA screws and posterior buttress plate used in posterior malleolar fixation of trimalleolar fractures. In this study, the data of 104 trimalleolar fracture cases treated surgically between October 2011 and January 2014 were extracted from hospital records. Patient demographics (age, gender, body mass index), the presence of syndesmotic injury, fracture type (according to the Lauge-Hansen classification), the size of posterior malleolar fragment (measured on lateral radiographs) were recorded. The patients requiring postoperative care for at least a year were invited to attend an evaluation of functional and radiological outcomes. At the final follow-up examination the functional evaluation was made by using AOFAS scores, VAS scores during walking, and dorsiflexion restrictions as compared with the unaffected side. As for the radiological evaluation, the patients were assessed according to the presence of a gap or step by the direct use of graphies following the fixation and with regard to the osteoarthritic development in alignment with the Bargon criteria. A total of 67 patients met the study inclusion criteria; 20 cases in the AP screw, 13 cases in the PA screw and 34 cases in the plate group. The mean follow-up period was 14.4 ± 2.23 months in AP, 16.3 ± 2.56 months in PA and 17.1 ± 3.01 months in the plate group. Better AOFAS scores were obtained in the PA group and the plate group compared to the AP screw group (p < 0.001). No statistically significant difference was found between the groups in respect of VAS scores during walking and dorsiflexion restriction. Better radiological reduction was observed in the PA screw group and the plate group (p < 0.001).

The Effect of C-Arm Mobility and Field of Vision on Radiation Exposure in the Treatment of Proximal Femoral Fractures: A Randomized Clinical Trial.

OBJECTIVES: To examine the effect of fluoroscopy devices with different sizes of image intensifier and C-arm maneuverability on operating time, fluoroscopy time, radiation dose and reduction, and fixation quality at intertrochanteric femoral fractures. DESIGN: Single-center, randomized, prospective study. SETTING: Academic Level I trauma hospital. PATIENTS AND INTERVENTION: 34 patients treated with cephalomedullary nailing for a stable, intertrochanteric proximal femur fracture (OTA A1). MAIN OUTCOME MEASUREMENT: The total working time of the fluoroscopy device, the dose-area product (DAP), operating time, reduction quality (cortical continuity, symmetrical collodiaphyseal angle, and shortness), and fixation quality (Bosworth quadrants, the tip-apex distance, TAD). RESULTS: There were no cases of poor reduction; also the placement of the blade was optimal for 14 patients and suboptimal in 3 patients in each group. Superior-posterior placement of the blade or TAD > 25 mm was not seen in any patient. Total operating time was significantly shorter when using device A compared to the use of device B (20.1 ± 3.4 mins versus 25.3 ± 5.4 mins, p < 0.001). Total radiation time was significantly shorter with device A compared to the use of device B (58.1 ± 19.4 secs versus 98.9  ±â€Šâ€Š55.4 secs, p = 0.008). The measured radiation dose was lower with the use of device A compared to device B (3.5  ±â€Šâ€Š1.2 Gy·cm2 versus 7.3  ±â€Šâ€Š4.5 Gy·cm2, p = 0.002). CONCLUSION: Physical properties of fluoroscopy devices used during the fixation of intertrochanteric fractures could yield significant differences in operating times and the radiation dose while having comparable clinical results.

Comparison of two closed surgical techniques at isolated pediatric radial neck fractures.

INTRODUCTION: This paper aims to compare the clinical and radiological results of children operated using elastic stable intramedullary nailing as described by Métaizeau to those with the closed reduction and percutaneous pinning (CRPP). METHODS: Results of 21 pediatric patients with radial neck fracture who were treated by two pediatric surgeons between January 2011 and December 2013 were reviewed retrospectively. 10 were treated with the Métaizeau method versus 11 with the CRPP. Operation time, fluoroscopic exposure time, Mayo elbow performance score (MEPS) and radiological assessment at final follow-up 1 year or greater and complications were main outcome measures. RESULTS: The MEPS were excellent in all the patients of both groups. Reduction quality was excellent in 8 patients and good in 2 of the Métaizeau, and excellent in 9 and good in 2 of the CRPP. The fluoroscopy and operating times were statistically significantly greater, 3-fold and 2-fold respectively, in the Métaizeau method compared to the CRPP with comparable functional and radiological results. CONCLUSION: Surgeon should adhere to a closed surgical method of his/her experience for excellent result. LEVEL OF EVIDENCE: Therapeutic Level III.

Impact of echocardiography on one-month and one-year mortality of intertrochanteric fracture patients.

OBJECTIVE: The aim of this study was to analyze the effects of preoperative echocardiography on patient survival, timing of surgery in length of hospital stay in patients who will undergo hip nailing for an intertrochanteric fracture. METHODS: The clinical records of the patients who were admitted to a tertiary university hospital with an intertrochanteric femur fracture were retrospectively analyzed. The age, gender, American Society of Anesthesiologists (ASA) score, days to surgery, total hospital stay, cardiac drug prescription/modification, cardiac intervention and presence of an echocardiography assessment including detailed findings were reviewed. Mortality data were accessed from the national civil registration system. RESULTS: 181 (110 women and 71 men; mean age 81 (44-98)) cases were studied whom 65 underwent pre-operative echocardiography. Time to surgery and total hospital stay was 2 days longer at transthoracic echocardiography (TTE) group (p < 0.001). At one month control group survival rate was 93.1% on contrary it was 75.4% at TTE group. One-year survival rates were 77.3% and 55.1% respectively. Likewise mean expected survival time was 21.6 ± 1.03 months for control group and 15.12 ± 1.64 months for TTE group (p < 0.001). Only increased left ventricular end diastolic diameter (LVEDD) was showed to be associated with increasing one-year mortality with a hazard ratio of 10.78 (2.572-45.19) at multivariate model. CONCLUSION: Cardiac findings and requisite for preoperative TTE and increased LVEDD is a strong predictor for mortality. TTE significantly lengthens the time to surgery. Also LVEDD measurement can be easily performed in the bedside which we believe would save time and reduce mortality. LEVEL OF EVIDENCE: Level III Diagnostic study.

Comparison of proximal femoral nail antirotation (PFNA) with AO dynamic condylar screws (DCS) for the treatment for unstable peritrochanteric femoral fractures.

PURPOSE: The aim of this study was to compare the results of intramedullary fixation with those of plate-screw fixation for peritrochanteric femoral fracture patients older than 60 years old. METHODS: This article reports on a retrospective review of patients who had peritrochanteric femoral fractures and were treated with a 95° fixed-angle screw plate (DCS) or an intramedullary nailing system (PFNA). Patients with 79 fractures were enrolled in the study; 47 of them were treated with the PFNA system and 37 with the DCS. Followed for at least 1 year, the treatment groups were compared by taking into consideration all demographic and trauma variables. RESULTS: No significant differences were discovered between the two groups with regard to side of injury, mechanism of trauma, associated comorbidities, AO fracture classification, average follow-up duration, mortality, and fracture reduction quality at the 1-year follow-up. The average surgical time was significantly lower in the PFNA group (57 min.) compared to the DCS group (87 min.). Longer operative time was needed in the DCS group, and thus, greater blood loss occurred compared to the PFNA group. The functional results of the PFNA group were found to be significantly better than those of the DCS group. CONCLUSIONS: Owing to some advantages, such as minimal exposure, reduced operative blood loss, and the achievement of biological fixation, PFNA is a better choice for the treatment for unstable peritrochanteric fractures.

Orthotic variations in the management of infantile tibia vara and the results of treatment.

BACKGROUND: Infantile tibia vara is an acquired form of tibial deformity associated with tibial varus and internal torsion. Several methods have been described for orthotics treatment. The purpose of this study was to determine the effectiveness of orthotics treatment in infantile tibia vara. STUDY DESIGN: Controlled trial. OBJECTIVE: The aim of this study was to compare the effect of different types of orthoses and correction methods on decreasing the curve in children with severe genu varum. METHODS: Three different types of knee-ankle-foot orthoses were applied to 35 lower extremities of 22 pediatric participants who were 19-38 months of age. The same orthotic design principles were used to correct the femur, while different designs were applied to correct the tibia. The orthoses used on 20 participants were evaluated for differences among them and their effects on the treatment process. In addition, methods used in the treatment, problems encountered, production of different types of orthoses, convenience of application of the orthoses, and degree of patients satisfaction are discussed in this article. RESULTS: The mean duration of treatment of the participants until completion of treatment was 25.3 ± 9.7 weeks with a minimum of 9 weeks and a maximum of 41 weeks. No statistically significant correlation was found between the duration of orthotic use in patients with a successful outcome and percentile height and percentile weight. When the duration of treatment using the different types of orthoses was analyzed, significant differences were found between Type 1 and Type 2, and Type 1 and Type 3 orthoses (p < 0.05), while no difference was observed between Type 2 and Type 3 orthoses (p > 0.05). CONCLUSION: We found that bracing is an effective form of treatment for infantile tibia vara up to 38 months of age. We conclude that full-time use of knee-ankle-foot orthoses exerting corrective forces from five points along the full length of the limb was effective.

Knee arthrodesis with Ilizarov's bone transport method for large infected periarticular defects: a report of three cases.

Large infected bone defects created by failed arthrodesis, tumoral resection, or posttrauma around the knee poses a great challenge to orthopedic surgeon. If prosthetic replacement has a high chance of failure; a knee arthrodesis can be considered for management. Three consecutive patients, treated between 2001 and 2003 for bone loss after tumor resection, failed knee arthrodesis and infected posttraumatic nonreconstructable knee joint were evaluated. After implant removal, debridement and irrigation, Ilizarov frame was applied for a knee arthrodesis with segmental bone transport through both femoral and tibial osteotomies. A second operation for the docking site refreshment was performed at the end of bone transport to enhance union. In all patients, a successful knee arthrodesis and acceptable alignment were achieved. Mean amount of bone transport was 173.3 mm (range, 110-220 mm). Average external fixator time was 10.1 month (range, 7.5-15 months) and average healing index was 18.5 d/cm (range, 10.2-23.6 d/cm). Equinovarus deformity occurred during treatment in two patients and was treated successfully with posteromedial release. Mean follow-up was 33.6 months after frame removal (range, 25-39 months). Neither had recurrence of pain and infection. We think knee arthrodesis with bone transport is an option to manage large infected bone defects that were not amenable for prosthetic replacement.

Compartmental anatomy of the superficial fibular nerve with an emphasis on fascial release operations of the leg.

Compartment syndrome is a common cause of lower extremity pain via an increased intra-compartmental pressure. Fasciotomy is currently the mainstay for surgical treatment. Fasciotomy can be performed either with classical open or minimally invasive techniques including endoscopically assisted or semi blind subcutaneous releases. Incompletely released fascial compartments, soft tissue damage, and neurovascular injury, which includes superficial fibular nerve injury are common complications. The aim of this study was to investigate the localization of the superficial fibular nerve (SFN) in the lateral and the anterior compartments. Thirty-eight legs of 20 cadavers fixed in 10% formaldehyde were dissected and the compartmental anatomy of the SFN investigated. Three particular types in the course of SFN were determined. In 71% of the cases, the SFN coursed entirely within the lateral compartment of the leg (Type I). In 23.7%, the SFN penetrated the anterior intermuscular septum, 12.7 cm inferior to the apex of the head of fibula and coursed in the anterior compartment (Type II). In the remaining 5.3% of the specimens the SFN had branches both in the anterior and lateral compartments (Type III). Knowledge of variations of the SFN with reference to compartmental anatomy of the leg may be useful in fascial release operations.

[Venous thromboembolism prophylaxis in major orthopaedic surgery: A multicenter, prospective, observational study]. / Majör ortopedik cerrahilerde venöz tromboemboli profilaksisi: Cokmerkezli, prospektif, gözlem çalismasi.

OBJECTIVES: We investigated risk factors for venous thromboembolism (VTE), prophylaxis measures employed, and incidence of symptomatic deep venous thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing major orthopaedic surgery (MOS). METHODS: An open, multicenter, prospective, observational study was conducted in 21 medical centers, comprising 899 patients. Of these, 316 patients (35.2%) underwent total hip arthroplasty (THA), 328 patients (36.5%) underwent total knee arthroplasty (TKA), and 255 patients (28.4%) underwent surgery for hip fractures (HF). Pharmacologic prophylaxis was employed in all the patients. RESULTS: Risk factors for VTE were seen in 73.2% of the patients, the most common being obesity (72%) and prolonged immobilization (36.3%). Low-molecular-weight heparin (91.1%) and fondaparinux (8.9%) were used for prophylaxis, which was short-term in 273 patients (30.4%) and long-term in 626 patients (69.6%). Mechanical prophylaxis was performed with compression stockings in 610 patients (67.9%) and by intermittent pneumatic compression in 67 patients (7.5%). During three-months of follow-up, symptomatic DVT and PE were seen in eight (0.9%) and four patients (0.4%), respectively. Mortality occurred in 10 patients (1.1%). Complications of major and minor bleeding were seen in eight (0.9%) and 40 (4.5%) patients, respectively. CONCLUSION: Effective VTE prophylaxis is associated with low risk of clinically apparent DVT and PE in MOS.

Cierny-Mader Type III chronic osteomyelitis: the results of patients treated with debridement, irrigation, vancomycin beads and systemic antibiotics.

Cierny-Mader (C-M) Type III osteomyelitis is defined as a localised lesion with both medullary and cortical involvement that is stable mechanically after debridement. The treatment of C-M Type III osteomyelitisis is difficult and requires a precise protocol to achieve a disease-free long-term follow-up. We report here the results of our study on 26 patients (19 men and 7 women; average age: 34.7 years) with C-M Type III osteomylelitis who were treated with radical debridement, irrigation, vancomycin-impregnated custom-made beads and culture-specific systemic antibiotics. Those patients with metaphyseal involvement were treated with deroofing of the cortex and debridement by means of a "trough" (16 patients); those with diaphyseal involvement were treated with both intramedullary reaming and debridement from a trough (ten patients). Antibiotic cement rods were used as an additional therapy in five patients with diaphyseal involvement. Recurrence developed in three patients and was attributed to inadequate debridement; all three patients were treated again in the same manner with success. The mean follow-up is currently 3.6 years (range: 2-6 years). All of the patients have normal clinical, radiographic and laboratory parameters, and all are ambulatory and have returned to their pretreatment level of activity or better. We conclude that C-M Type III chronic osteomyelitis can be safely treated with this protocol.

[Radical reduction for developmental dislocation of the hip (Cakirgil's procedure)]. / Gelisimsel kalça displazisinde radikal redüksiyon (Cakirgil ameliyati).

This paper describes the so called "radical reduction of the hip" (Cakirgil's) procedure for children above four years of age, with high developmental dislocation of the hip. The procedure is a combined one-stage operation including adductor tenotomy, open reduction, femoral shortening, proximal femoral varus-derotation osteotomy and Dega's osteotomy. Radical reduction is a safe and effective procedure for high dislocations with shallow acetabulum.

Extensile triradiate approach in the management of combined acetabular fractures.

INTRODUCTION: We investigated the results of combined acetabular fractures that were treated through the extensile triradiate approach in this study. MATERIALS AND METHODS: Between January 1996 and January 2001, a total of 48 acetabular fractures were treated surgically (mainly combined fractures). Twenty-five of the combined acetabular fractures that were surgically treated through the triradiate approach with a minimum of 2 years' follow-up were included in the study. The mean patient age was 42 years. There were 8 both-column, 6 T-shaped, 2 anterior column/posterior hemitransverse, 4 transverse with comminuted roof area, 4 posterior wall with comminuted roof area, and 1 posterior column/posterior wall fracture. Associated injuries included two full-thickness chondral injuries of the head, one Pipkin type II fracture, five posterior and one central dislocation of the ipsilateral femoral head, and acetabular marginal impaction in four hips. The average follow-up was 44 months. RESULTS: The postoperative reduction was graded as excellent in 68% and imperfect in 8% of the patients. The hips were evaluated functionally according to the modified Postel-D'Aubigne score and rated as excellent in 7 patients (28%), good in 13 patients (52%), fair in 3 patients (12%) and poor in 2 patients (8%). There were 2 deep infections (8%), 2 avascular necroses of the head (8%), and 4 (16%) non-disabling heterotopic ossifications. CONCLUSION: Our results support the idea that open reduction with the triradiate approach provides good visualization and direct reduction of combined acetabular fractures. Its learning curve for combined fractures is shorter than that for single approaches and provides at least the same rate of anatomical reduction. It should be in the armamentarium of a surgeon dealing with such fractures.

Slipped capital femoral epiphysis in osteopetrosis: an unusual case.

We report on a 9-year-old boy who has type II autosomal dominant osteopetrosis associated with a chronic grade II slipped capital femoral epiphysis. He was treated with a single cannulated screw. This rare association has been reported only once.