Nail breakage in patients with hypertrophic pseudoarthrosis after subtrochanteric femur fracture: treatment with exchanging nail and decortication.

In this study, we aimed to show the results of exchange nail and decortication in patients whose subtrochanteric femur fractures were treated with intramedullary nails and subsequently developed fracture nonunion and nail breakage com- plications. This study consisted of patients presenting with subtrochanteric femur fractures between January 2013 and April 2019 who underwent surgery and later experienced nail breakage due to hypertrophic nonunion. There were a total of 10 patients aged 26-62 years (Avg 40,30, SD: 9,989). Nine patients were smokers, and 1 patient had diabetes and hypertension. Three patients were admitted to the trauma center due to a car accident and 7 patients were admitted because of a fall. The infection parameters of all patients were normal. All patients had pathological movement complications and pain at the fracture site. Preoperatively, medulla diameter was measured with standard radiography in all patients. The diameters of the old nails applied to the patients ranged from 10 to 12 mm, and the diameters of the newly applied nails ranged from 14 to 16 mm. The fracture lines of all patients were opened to remove the broken nails, and decortication was performed. No additional autograft or allograft was applied to any patient. Union was achieved in all patients. We conclude that the use of larger diameter nails in conjunction with decortication will prevent nail breakage, improve healing and provide early union in patients with subtrochanteric femur fractures with hypertrophic pseudoarthrosis.

Is arthroscopic assisted double tibial tunnel fixation a good option for tibial eminentia fractures?

Tibial eminentia fractures are avulsion fractures of the anterior cruciate ligament caused with additional injuries like meniscus tears or ligamentous injuries. Arthroscopic assisted internal fixation has become a preferred technique with the development of arthroscopic techniques. We aimed to present our results for arthroscopic assisted double tibial tunnel fixation in patients with displaced eminentia fracture. Twenty patients who were operated on for eminentia fracture between January 2010 and May 2014 were included in this study. All fractures were type II according to Meyers's classification. Eminentia was reduced with two nonabsorbable sutures through the ACL. Two tibial tunnels were created over the medial proximal tibia with a 2.4 mm cannulated drill. The two suture ends taken out of the 2 tibial tunnels were connected on the bone bridge between the tunnels. Patients were evaluated with Lysholm score, Tegner score, IKDC score and examined for clinical and radiological evidence of bony union. Quadriceps exercises were started on the third day. The patients were followed up with a locked knee brace in extension for 3 weeks after surgery and later patients were encouraged to mobilize as pain allowed. The preoperative Lysholm score was 75 ±3.3 and the postoperative Lysholm score was 94.5 ±3. Tegner score was 3.52±1.02 preoperatively and 6.84±1.099 postoperatively. International Knee Documentation Committee(IKDC) score was abnormal in all of the 20 patients preoperatively but normal postoperatively. The postoperative scores of the patients were statistically significant when compared with preoperative activity scores(p<0,0001). Tibial eminentia fractures may lead to pain, knee instability, malunion, laxity, or extension deficit. The technique we have described together with early rehabilitation may give good clinical results.

Derotation of the mallet piece: A crucial point in mallet fracture surgery.

Mallet fracture is an avulsion of the extensor tendon and fracture of the dorsal rim of the articular surface of distal phalanx at the same time. If a part of the mallet fracture is angled or rotated to such a degree that prevents full anatomic reduction, malunion and deformities may occur as a result. The objective of this study was to describe a new surgical technique to provide derotation of the mallet fracture. A 22G or 21G needle is used like a joystick to reduce the mallet fracture with small, gentle movements. The extension block pinning technique described by Ishiguro was applied after proper alignment had been achieved. Bony union was achieved for all patients 6 weeks later. Derotation of type 2 and 3 mallet pieces with closed reduction to prevent surgical failure is simple but effective.

Results of percutaneous fixation and distal radius core decompression in scaphoid waist non-unions treated without grafting.

Scaphoid non-union management is still a challenge in clinical practice for orthopaedic surgeons. Though several treatment methods have been described, there is an ongoing debate about optimum management. Based on new concepts about avascular conditions, promising results were reported with metaphyseal decompression of the distal radius by increasing the vascularization of the radial column of the carpus. We aimed to evaluate the clinical, radiological, and functional outcomes of distal radius core decompression and fixation with palmar percutaneous cannulated compression screws without grafting in patients with scaphoid waist fracture non-union. Twenty-nine patients with scaphoid non-union were included in this prospective study. There were 27 male and 2 female patients with an average age of 29 years (range 18-45 years). Mean time from the injury to surgery was 18.3 months. The Slade and Geissler classification was used to classify the non-unions. Wrist range of motion (ROM), pain based on a visual analog scale (VAS), and the Mayo wrist score were used to assess the clinical outcomes. Postoperative radiographs and CT-scans were reviewed to assess fracture union, carpal alignment and screw position. The average clinical follow-up was 76 weeks (range: 74-87 weeks) postoperatively. Mean time to union was 11 weeks (range: 7-18 weeks). There was no humpback/no DISI in any of the cases. Twenty-six patients healed successfully with no additional procedures. Three patients with failed union underwent revision surgery with grafting. At the final follow-up, average wrist ROM was 61° (range: 30-80) in extension and 61° (range: 35-80) in flexion, the average Mayo wrist score was 66±20 (range: 20-90), and the mean VAS was 2±2 (range: 0-7). Percutaneous fixation without grafting associated with distal radius core decompression can provide satisfactory outcomes in surgical management of scaphoid non-unions. LEVEL OF EVIDENCE: II.

Medial Spike and Obesity Associate with Open Reduction in Type III Supracondylar Humeral Fracture.

UNLABELLED: PURPOSE OF THE STUDY Although supracondylar humeral fractures represent a major part of the pediatric fractures, no classification system or radiological characteristics describes which supracondylar fractures require open reduction. We aim to evaluate the factors that lead us to perform open reduction during operation. MATERIAL AND METHODS We retrospectively evaluated 57 patients who underwent operation for type III supracondylar fracture, and divided them into two groups; those with open reduction and internal fixation, and those with closed reduction and percutaneous fixation. The two groups were compared based on age, gender, BMI by age, medial spike angle of the fracture, medial spike-skin distance and rotation angle between the fractured fragments. RESULTS Of all patients, 46 (81.71%) underwent closed reduction and percutaneous fixation (CRPF) and 11 (19.29%) were treated with open reduction and internal fixation (ORIF). BMI by age was remarkably higher in the ORIF group (p = 0.00). And medial spike angle was smaller in the ORIF group (p = 0.014). DISCUSSION Closed reduction and percutanous fixation is the main treatment of supracondylar humeral fractuers. Open reduction in supracondylar humeral fractures could be associate with complications and cosmetic lesions. Many studies indicates that obesity is high risk factor for complex fractures as well as preoperative and postoperative complications. A prominant medial spike could associate with muscle entrapment, and obliquity of the fracture line. It could be also an indirect finding of instablity of the fracture. CONCLUSION We suggest that a smaller medial spike angle and a higher BMI in children with Type III supracondylar humeral fractures may require open reduction, and it is unreasonable to avoid open reduction in cases where closed reduction is not achieved. KEY WORDS: supracondylar humerus, open reduction, obesity, medial spike angle.

Angular deformity development after the distal tibial physeal fractures.

Several clinical and radiological factors can be prognostic in the development of angular deformity following physeal injuries of the distal tibia. One of the radiological parameters, premature physeal closure (PPC), can be detected during postoperative follow-ups. Aim of our study was to identify the prognostic factors in development of angular deformity and its relationship with PPC. One hundred and four patients treated due to physeal injuries of the distal tibia were included in our study. Patients were divided into three groups based on Salter-Harris (SH) classification. The intergroup relationships between sex, age, the amount of energy sustained during injury, premature physeal closure, the amount of residual gap, and deformity were analyzed. Angular deformity developed in 25% (3/12) of SH Type 2, in 60% (9/15) of Type 3 and 30% (3/10) of Type 4 patients with PPC. A residual displacement of more than 2 mm, age and premature physeal closure were specified as significant risk factors for development of angular deformity. 2 mm limit for residual displacement and findings of premature physeal closure in the radiological evaluations during follow-ups are prognostic factors in avoiding malalignment of the distal tibia. LEVEL OF EVIDENCE: Level 3.