Which parameters are more reliable in proximal humerus surgery in terms of the axillary nerve?

OBJECTIVES: This study aims to examine the reliability of the old and new parameters in determining the axillary nerve safe area for surgical interventions in the proximal humerus by measuring the distances between the top of the humeral head, the top of the greater tuberosity, the base of the greater tuberosity, and the acromion and axillary nerve. PATIENTS AND METHODS: Between 2020 and 2022, a total of 52 shoulders of 26 fresh frozen male human cadavers (mean age: 46±25.5 years; range, 28 to 64 years), 26 right and 26 left were included. The deltopectoral approach was used. The intersection distances of the anterolateral end of the acromion, the top of the humeral head, the top of the tuberculum majus, and the base of the tuberculum majus with the N. axillaries were determined. All measurements were performed using the Microscribe® G2X. RESULTS: The mean distance from the top of the tuberculum majus to the axillary nerve (shown as "A") was measured as 4.36±0.17 cm and 4±0.21 cm on the right and left, respectively. The mean distance from the center of the base of the tuberculum majus to the axillary nerve (shown as "B") was measured as 1.27±0.18 cm and 1.24±0.11 cm on the right and left, respectively. The mean distance from the apex of the humeral head to the axillary nerve (shown as "C") was measured as 6.15±0.39 cm and 5.89±0.34 cm on the right and left, respectively. The mean distance between the anterolateral end of the acromion (shown as "D") was measured as 6.15±0.39 cm and 5.89±0.34 cm on the right and left, respectively. There was a moderate positive correlation between distances A and B measured on the right and left side, respectively (r=0.484; p=0.012) (r=0.454; p=0.020). CONCLUSION: A strong positive correlation was found between the distances A and B. The A, B, and C parameters had a weak correlation with parameter D. The anatomical parameters A and B was found to be less variable and more reliable than parameter D.

Outcome of Locked Compressive Nailing in Aseptic Tibial Diaphyseal Nonunions without Bone Defect.

BACKGROUND: Treatment of tibial diaphyseal nonunions are rather difficult. Plate-screw, intramedullary nailing and external fixation are the methods used for treatment. The aim of this study is to evaluate the treatment results of aseptic diaphyseal nonunions following tibia fractures by intramedullary compressive tibia nailing (IMCN) with or without bone graft. MATERIALS AND METHODS: Twenty eight patients who had aseptic tibial nonunion without bone defects operated between 2005 and 2015 were included in the study. The mean age of our patients was 36.4 years (range 20-56 years). There were 22 males and 6 females. Fifteen of the patients exhibited hypertrophic nonunion and thirteen exhibited atrophic nonunion. The average time between fracture occurrence and presentation to our department was 1.6 years (range 1-20 years). All patients underwent fibular osteotomy by removal of a 2 cm bone block from the middle one-third of the fibulas. In all cases, IMCN was applied following the reaming procedure, then maximum bone contacts were achieved manually between proximal and distal bone fragments afterward, and dynamic compressive fixation with 1 mm of compression was performed by a single rotation of the compression screw at the top of the nail. Direct X-ray images were assessed according to the Rust criteria, and functional outcomes were assessed according to the Johner-Wrush criteria. Finite-element analysis was performed for 1 mm of compression. For statistical analysis, Fisher's exact test, Pearson's Chi-square test, and Mann-Whitney U-test were used. RESULTS: Union was achieved in all patients. Radiological union was obtained at an average of 15.5 ± 1.86 weeks. Functional results were found to be good or excellent in 25 (89.2%) patients and average or poor in 3 (10.8%) patients. One patient developed skin necrosis at the wound site, which was treated with rotational flap and skin graft. None of the patients developed implant failure, thromboembolism, deep-vein thrombosis, or infection. CONCLUSIONS: The use of compressive intramedullary nailing with or without bone graft is an effective method for the treatment of tibial nonunion.

Effect of intramedullary nail compression amount on the union process of tibial shaft fracture and the evaluation of this effect with a different parameter.

OBJECTIVES: This study aims to investigate the effects of different amounts of compression used in intramedullary nailing on the stress values of the fracture surface and time of the union process in tibia diaphysis fractures treated with intramedullary nails. PATIENTS AND METHODS: Seventy patients (50 males, 20 females; mean age 34.0±10.7 years; range, 20 to 56 years) who had suffered from tibial shaft fractures between January 2007 and December 2015 were included in the study. Patients who had A2, A3, and B2 type fractures according to AO (Arbeitsgemeinschaft für Osteosynthesefragen) classification and those with closed fractures were included. The patients were divided into three groups. No compression was applied to Group A, dynamic compressive fixation intramedullary nailing was applied to Groups B and C. Amount of applied compression was 1 mm for Group B and 1.5 mm for Group C. Postoperative and follow-up radiographs of patients were evaluated according to Rust criteria, and functional results were evaluated according to Johner-Wrush criteria. Additionally, finite element analyses were performed separately for 1 mm and 1.5 mm compressions that were applied in Group B and C, respectively. The data were analyzed using a statistical software package. RESULTS: Clinical and radiological union was achieved in all patients. The average time of radiological union was 15.05±2.06 weeks in Group A, 12.48±1.42 weeks in Group B, and 11.64±1.63 weeks in Group C. The time of union for the group in which no compression was applied (Group A) was significantly longer than the other groups in which compression was applied (Group B and C) (p<0.001). Functional outcomes were 17 patients (85%) with excellent and three patients (15%) with good-moderate results in Group A, 23 (92%) excellent and two (8%) good-moderate in Group B, and 23 (92%) excellent and two patients (8%) with good-moderate results in Group C. In total, seven patients had knee pain. No infection was seen in any patient. CONCLUSION: Interlocking compression intramedullary nailing is a very effective treatment method for tibial shaft fractures. As the compression applied by the nail increases, the time of union shortens significantly.

Is locked compressive intramedullary nailing for adult humerus shaft fractures advantageous?

OBJECTIVES: This study aims to evaluate the radiological and functional outcomes of locked compressive intramedullary nailing (IMN) cases in adult humerus shaft fractures. PATIENTS AND METHODS: A total of 24 patients (12 males, 12 females; mean age 42 years; range 23 to 55 years) with humerus fractures were treated with locked compressive IMN at the Orthopedics and Traumatology Clinic, Antalya Training and Research Hospital between December 2009 and March 2015. Fluoroscopy was used only to check fracture reduction before the reaming procedure. Of the patients, closed IMN was performed in 21, while open reduction was performed in three. Lock screws were locked without fluoroscopy in all patients. Of the patients in whom open reduction was performed, radial nerve lesion developed in one. Anteroposterior and lateral graphs of all patients were taken postoperatively. Fracture union was assessed according to existence of the fracture line and the callus tissue in the anteroposterior and lateral graphs. The Constant-Murley scoring system was used for functional evaluation. The mean follow-up period was 24 months (range 12 to 72 months). Finite element analysis was performed for the stress distribution on fracture site. RESULTS: Radiological fracture union was achieved in all patients at mean 14.8 weeks (range 12 to 17 weeks). The Constant-Murley score was mean 90 (range 72 to 100). There was a statistically significant, negative and strong correlation between union period and the Constant-Murley score (r=-0.78, p<0.001). In one patient who developed postoperative radial nerve symptoms, all functions were regained in fourth month. No infection occurred in any patient. In two patients, tip of the nail remained high. Of these patients, one developed impingement findings, and the other patient had no problems. CONCLUSION: Treatment of humerus shaft fractures with locked compressive IMN provides sufficient fixation and early movement opportunity in the shoulder and elbow joints, and gives satisfactory radiological and functional results.

Is it possible to avoid intra-articular screw penetration with minimal use of fluoroscopy in the application of distal radius volar plate?

OBJECTIVES: This study aims to investigate whether or not it is possible to avoid intra-articular screw penetration in the application of distal radius volar plate with minimal use of fluoroscopy and thereby reduce to a minimum the risk of exposure of the surgical team to radiation. PATIENTS AND METHODS: Volar plate with distal screw application with minimal use of fluoroscopy was performed in a total of 50 patients (22 males, 28 females; mean age 43.52 years; range 18 to 76 years) with unstable distal radius fracture following reduction of fracture between June 2014 and May 2016. A specially designed volar anatomic plate was applied by creating a 3 mm gap proximal from the tip of the facet of the lunate fossa. RESULTS: No intra-articular screw complication was observed during plate-screw applications that we performed by using fluoroscopy at a minimum level and paying attention to the surgical technique described with the plate designed by giving a specific angle to screw beds. During the operation, fluoroscopy was performed at a minimum level and no finding was observed which could suggest use of intra-articular screw. No findings of restriction in wrist movements, locking or friction were observed intra- or postoperatively. CONCLUSION: With improvements in the design of the volar plate and the distal locking screw bed, it is possible to rule out the possibility of intra-articular screw complications and the need for surgical re-correction in the early-term, and to reduce to a minimum the risk of exposure of the surgical team to radiation.

Comparison of non-compression and compression interlocking intramedullary nailing in rabbit femoral shaft osteotomy model.

OBJECTIVES: This study aims to compare non-compression and compression intramedullary nailing in an experimental femoral shaft osteotomy model in terms of radiological, histological, and biomechanical aspects. MATERIALS AND METHODS: Twenty-four white New Zealand rabbits (average weight 4.3 kg; range 4 to 4.8 kg) were divided into three groups. A right femoral osteotomy was performed in all rabbits and all femurs were fixed with titanium compression interlocking intramedullary nail. After locking of nails, no compression was performed in group 1 while 0.5 mm and 1 mm compressions were performed in group 2 and 3, respectively. All rabbits were sacrificed four weeks after operation. Fracture sites were examined histologically and radiologically. Finite element analyses were performed. RESULTS: Radiological scores of groups 2 and 3 were significantly higher than group 1. There was no significant difference between groups 2 and 3 radiologically. Best histological scores were achieved in group 2. According to finite element analyses, osteotomy site in group 2 was exposed to 1240 N of load and 34.5 MPa of mean stress. CONCLUSION: Compression interlocking intramedullary nailing provides faster fracture healing than non-compression interlocking intramedullary nailing. Best histological fracture healing scores were obtained with 0.5 mm compression performed at the fracture site.

[Morphometric anatomic study and clinical significance of lunate fossa]. / Lunat fossanin morfometrik anatomik çalismasi ve klinik önemi.

OBJECTIVES: This study aims to investigate the depth, transverse and sagittal diameters of lunate fossa which is a significant structure of the wrist in terms of reducing the risk for volar plate screws, which are administered in distal radius fractures, from penetrating into the joint. MATERIALS AND METHODS: Depth, transverse and sagittal diameters of lunate fossa in 50 right and 50 left adult dried radius bones without distal tip damage were measured by using MicroscribeG2X from the MicroScribe G series. RESULTS: Mean lunate fossa depth: left 2.419886±0.51 mm/right 2.543052±0.78 mm, mean lunate fossa sagittal diameter: left 19.656±1.57 mm/right 18.796±1.53 mm, mean lunate fossa transverse diameter: left 11.382±0.65 mm/right 11.106±0.91 mm. There was no statistically significant difference between right and left depth values of lunate fossa (p=0.320), whereas there was statistically significant difference between right and left transverse and sagittal diameters (p=0.006, p=0.048). CONCLUSION: Measurements involving depth of lunate fossa may guide the development of new anatomic plates and decrease complications like the penetration of screw into joint whilst volar plate administrations.

[Distal locking techniques without fluoroscopy in intramedullar nailing]. / Intramedüller çivilemede floroskopi olmadan distal kilitleme teknikleri.

OBJECTIVES: In this study, we present three distal locking techniques and two checking methods in intramedullar nailing. PATIENTS AND METHODS: Between January 1999 and December 2011, we performed distal locking with locked intramedullary nails on 501 femoral bone fractures using bone alignment and aspiration technique without fluoroscopy and 578 tibial bone fractures using medial malleolus alignment, bone alignment and aspiration technique without fluoroscopy at Antalya Training and Research Hospital. RESULTS: With the combination of these three locking techniques and two checking methods, locking was successful in all cases except one. In the latter case, the nail remained anteriorly, as the distal screws were not fully compliant with the surgical technique. CONCLUSION: Distal locking can be achieved in a short time using one or combining two or more techniques and methods without fluoroscopy.

Dislocated ankle fracture complicated by near total distal ischaemia.

Total arterial ischaemia is rarely seen following a dislocated ankle fracture but if it does and intervention is not made, it can lead to serious morbidity. We present a 39-year-old woman with almost total occlusion in the arteria tibialis and arteria dorsalis pedis following a dislocated ankle fracture as a result of a bicycle fall.

Isolated unilateral absent patella and contralateral small patella.

Isolated bilateral absent patella is seen very rarely. It is generally encountered as a part of nail-patella syndrome. An 18-year-old male patient presented with left absent patella and right small patella.