Single versus double plate fixation of humeral shaft nonunion.

INTRODUCTION: Humeral shaft fractures are common fractures of the diaphysis of the humerus. The aim of this study was to evaluate factors affecting the clinical outcomes of humeral nonunions surgically treated with open reduction and single- versus double-plate fixation with grafting. MATERIALS AND METHODS: A total of 31 patients with nonunion treated with single- or double-plate screw fixation with bone grafting were retrospectively analysed. The patients were divided into two groups according to the treatment method as Group 1 (single-plate, n = 14) and Group 2 (double-plate, n = 17). Data including demographic and clinical characteristics of the patients, initial and final treatment, type of nonunion and localisation, graft use, shortening, follow-up, time to union, Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH) scores, and patient-reported cosmetic outcomes were recorded. RESULTS: Of the patients, eight were males, and 23 were females, with a mean age of 47.6 ± 15.8 (range, 20-86) years. Initial treatment was conservative treatment (Sarmiento brace) in seven patients, plate fixation in 22 patients, and intramedullary nailing in two patients. The mean follow-up was 31.0 ± 16.9 months in Group 1 and 25.4 ± 15.6 months in Group 2. There was one nonunion in Group 1 and three in Group 2. There were no significant differences in the union rate and time to union (p = 0.378 and p = 0.262, respectively). The mean Quick-DASH scores and cosmetic results were similar between the groups (p = 0.423 and p = 0.165, respectively). Radial nerve palsy developed in three patients in Group 2, and all these patients recovered completely during follow-up. CONCLUSIONS: Although the double-plate fixation technique has similar clinical, radiological, and functional results to single-plate fixation, it is a more invasive and expensive technique with a longer operation time. Therefore, it should not be used as the first-line treatment option for all humeral shaft nonunion. Nevertheless, the double-plate technique may be preferred to achieve in cases requiring high stability, such as hypertrophic nonunion, osteopenia and comminuted fractures.

Comparison of volar versus dorsal screw fixation for scaphoid waist fractures: A finite element analysis.

PURPOSE: Scaphoid waist fractures may be fixed through volar or dorsal screw fixation. However, there is no consensus on which surgical fixation method should be performed. The purpose of this study was to compare volar versus dorsal screw fixation of scaphoid waist fractures under physiological loading conditions utilizing finite element analysis. METHODS: A transverse scaphoid waist fracture (Herbert type B2) model was fixed with a headless cannulated compression screw using either a volar or dorsal approach. Displacement and rotation of the fragments and stress analysis on the scaphoid bone and screw were analyzed in the models using 3-D finite element analysis in three different wrist positions; total extension (TE), neutral (N) and total flexion (TF). RESULTS: Displacement of the fracture gap in volar fixation in all planes (x, y, z) was less than in dorsal fixation in the TF and N positions. Furthermore, rotational stability was stronger in volar fixation in all planes and wrist positions. von Mises stress values were concentrated on the proximal fragment in all wrist positions. CONCLUSIONS: Although both volar and dorsal fixation techniques can be preferred in Herbert type B2 fractures, results of this finite element analysis suggest that centrally placed volar compression screw fixation may be biomechanically advantageous over dorsal screw fixation. LEVEL OF EVIDENCE: I.

Inter- and Intraobserver Reliabilities of Four Different Radiographic Grading Scales of Osteoarthritis of the Knee Joint.

The purpose of this study was to investigate the interobserver and intraobserver reliabilities of four different radiographic grading scale of osteoarthritis (OA) of the knee joint, namely, Kellgren-Lawrence (KL), Ahlback, Brandt, and OA Research Society International (OARSI). One consultant orthopaedic surgeon and one rheumatologist who were familiar with these OA grading scales participated in the study. Radiological assessments were performed in random order by each observer on two separate occasions, at least 2 weeks apart. K-statistics were used to establish a relative level of agreement between the observers for the two readings and between separate readings by the same observer. A total of 140 patients (53 males and 87 females) with a mean age of 61.2 years (range, 50-72 years) were included in the study. Intraobserver reliability for KL was substantial for observer A (κ: 0.753) and moderate for observer B (κ: 0.573). Interobserver reliability for KL was moderate for both observers (κ: 0.499 and 0.458, respectively). Intraobserver reliability for Ahlback was substantial for observer A (κ: 0.768) and moderate for observer B (κ: 0.561). Interobserver reliability for Ahlback was fair for both observers (κ: 0.365 and 0.204, respectively). Intraobserver reliability for Brandt was substantial for observer A (κ: 0.741) and moderate (κ: 0.425) for observer B. Interobserver reliability for Brandt was fair for both observers (κ: 0.308 and κ: 0.246, respectively). Intraobserver reliability for OARSI was substantial for observer A (κ: 0.792) and moderate for observer B (κ: 0.508). Interobserver reliability for OARSI was moderate for observer A (κ: 0.425) and slight for observer B (κ: 0.175). None of the studied OA grading scales showed acceptable reliability (κ > 0.80). The evaluation of patients with OA should not be dependent on radiographic findings alone; clinical findings should also guide the treatment and follow-up.

Isolated Adult Tillaux Fracture Associated With Volkmann Fracture-A Unique Combination of Injuries: Report of Two Cases and Review of the Literature.

Avulsion fractures of the anterior inferior tibiofibular ligament from its tibial attachment, Tillaux fractures, are usually seen in adolescents during the interval of the distal tibial epiphyseal closure. However, this pattern of fracture is rare in adult patients, because the ligaments will usually fail before the bone fails. Avulsion fracture of the posterior inferior tibiofibular ligament from its tibial attachment, Volkmann fracture, is the posterolateral counterpart of a similar injury. In the present study, the cases of 2 adult patients with simultaneous Tillaux and Volkmann fractures are reported and the mechanism of injury, diagnosis, and treatment discussed. This fracture pattern is extremely rare and, to the best of our knowledge, has not been previously reported.

Removal of a bent intramedullary nail in lower extremity: report of two cases and review of removal techniques.

Removal of a bent intramedullary nail (IMN) is a rare but challenging orthopedic problem. Several removal techniques have been described up to date; however, there is no extensive review and no algorithm to manage these cases in current literature. The purpose of this paper is to present two cases that presented with bent IMN and provide an algorithm for management of this rare complication.

Functional outcomes and complications after surgical repair of triceps tendon rupture.

OBJECTIVE: The purpose of this study was to present the functional outcomes and complications after primary repair of triceps tendon ruptures (TTR). PATIENTS AND METHODS: A retrospective review was performed on eight patients (six males, two females) who underwent transosseous suture repair for TTR. Mayo elbow score, range of motion, muscle strength and patient satisfaction were evaluated after at least 1-year follow-up. RESULTS: The mean age of the patients was 25.1 years (range 16-42). The mechanism of injury was a sports injury in three patients, simple fall (fall on outstretched hand) in four and motorcycle accident in one patient. Two patients had associated radial head fracture, and one had a radial head fracture and trochlear fracture, and one patient had a medial epicondyle fracture. In two patients the diagnosis was missed at the initial admission to ED (delay, 20 and 75 days). Only one patient, who was a bodybuilder, had a history of anabolic steroid use, and the rest had no underlying disease or a predisposing factor for TTR. One of the patients with radial head fracture (displaced three parts) underwent simultaneous fixation using two headless screws. Patients were followed up for a mean of 18.8 months (range 12-26). At the final follow-up, all patients were satisfied with the treatment and the Mayo elbow score was excellent in six patients and good in two patients. There was 5° extension loss in two patients. Triceps muscle strength was 5/5 in all patients. Ulnar nerve entrapment occurred in one patient, so ulnar nerve release and anterior transposition were performed 3 months after surgery. Posterior interosseous nerve palsy occurred in one patient who underwent simultaneous radial head fracture fixation, but eventually returned back to normal 3 months postoperatively. All patients returned to their previous level of activity and occupation. CONCLUSION: Transosseous suture technique is a safe and effective treatment method for acute TTR with a low rate of complications and excellent functional outcomes. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Finite element analysis of the stability of transverse acetabular fractures in standing and sitting positions by different fixation options.

BACKGROUND: Treatment of a transverse acetabular fracture type is possible from an anterior approach, a posterior approach or both. Different fixation methods have been described but whether one is superior to the other is still under debate. The aim of the current study was to test the different fixation alternatives of stabilization of transverse acetabular fractures under two basic physiological loading conditions: standing and sitting utilizing a finite element model. MATERIAL AND METHODS: A transtectal transverse fracture model was fixed in five different alternatives: an anterior column plate; a posterior column plate; an anterior column plate combined with a posterior column screw; a posterior column plate combined with an anterior column screw; and a posterior column plate and an anterior column plate. In these models, a load of 400N was applied at standing and sitting positions and the displacements were analyzed by using three-dimensional finite element stress analysis method. RESULTS: In the model simulating standing human position, overall motion at the posterior column was minimum when two columns were plated (0.071mm). The second best fixation was posterior column plate with an anterior column screw (0.077mm). Overall motion at the anterior column was minimum by posterior column plate with an anterior column screw (0.0326mm). The plating of two columns was associated with motion of (0.0333mm). In the model that simulates sitting position, the motion at the posterior column was minimum when two columns were plated (0.0478mm), and (0.0517mm) when a posterior column plate with an anterior column screw was used. Overall motion in the anterior column was minimum when posterior column plate with an anterior column screw (0.0198mm) was used, whereas the motion was (0.0203mm) when plating of both columns was examined. CONCLUSION: Posterior column plating combined with an anterior column screw has quite comparable results to a both column plating in transverse fractures, suggesting that two column fixations might be unnecessary. This method is also very superior to anterior column plating combined with a posterior column screw in that type of fractures.

Effect of surgical closing in total knee arthroplasty at flexion or extension: a prospective, randomized study.

PURPOSE: The aim of this study was to evaluate the effect of knee position during wound closure (flexed vs. extended) in total knee arthroplasty on knee strength and function, as determined by knee society scores and isokinetic testing of extensor and flexor muscle groups. METHODS: In a prospective, randomized, double-blind trial, 29 patients were divided in two groups: for Group 1 patients, surgical closing was performed with the knee extended, and for Group 2 patients, the knee flexed at 90°. All the patients were treated with the same anaesthesia method, surgical team, surgical technique, prosthesis type, and rehabilitation process. American Knee Society Score values and knee flexion degrees were recorded. Isokinetic muscle strength measurements of both knees in flexion and extension were taken using 60° and 180°/s angular velocity. The peak torque and total work values, isokinetic muscle strength differences, and total work difference values were calculated for surgically repaired and healthy knees. RESULTS: No significant difference in the mean American Knee Society Score values and knee flexion degrees was observed between the two groups. However, using isokinetic evaluation, a significant difference was found in the isokinetic muscle strength differences and total work difference of the flexor muscle between the two groups when patients were tested at 180°/s. Less loss of strength was detected in the isokinetic muscle strength differences of the flexor muscle in Group 2 (-4.2%) than in Group 1 (-23.1%). CONCLUSION: For patients undergoing total knee arthroplasty, post-operative flexor muscle strength is improved if the knee is flexed during wound closure. LEVEL OF EVIDENCE: II.

Does platelet-rich plasma enhance microfracture treatment for chronic focal chondral defects? An in-vivo study performed in a rat model.

OBJECTIVE: The purpose of the present study was to compare the effectiveness of platelet-rich plasma (PRP) + microfracture and microfracture treatments in the healing of chronic focal chondral defects. METHODS: The study included 57 adult male Sprague-Dawley rats. Forty-two rats were divided into three groups of 14 rats with a chondral defect (control, microfracture only, PRP+microfracture). The remaining 15 rats were used to produce the PRP preparation. The rats were then euthanatized at 3 and 6 weeks after treatment and examined. Histological analysis using the modified Pineda scoring system and immunohistochemical staining for Type 2 collagen were performed. RESULTS: At both time intervals, control group histological scores (Week 3: 8.8±1.2, Week 6: 8.5±0.7) were higher than microfracture (Week 3: 6.8±1.0, Week 6: 7.1±0.6) and PRP+microfracture (Week 3: 6.4±1.3, Week 6: 5.7±1.2) scores (p<0.05). The microfracture group score was higher at Week 6 than the PRP+microfracture group (p<0.05). The degree of Type 2 collagen staining was higher at Week 6 in the PRP+microfracture group and was unique in showing staining at the cell membrane. CONCLUSION: The addition of PRP application to microfracture treatment appears to enhance cartilage healing in chronic focal chondral defects.

Adjunctive hyperbaric oxygen therapy in the treatment of atrophic tibial nonunion with Ilizarov external fixator: a radiographic and scintigraphic study in rabbits.

OBJECTIVE: The aim of this experimental study was to determine the effects of adjunctive hyperbaric oxygen therapy (HBO) on atrophic tibial nonunion treatment using Ilizarov external fixator. METHODS: Twenty New Zealand white rabbits were randomly divided into two equal groups. A circular external fixator was applied to the right tibia of all the rabbits. A 5-mm bone block was resected and a tibial pseudarthrosis was obtained after a 6-month waiting period. The experimental group rabbits (n=10) underwent daily 2.5 ATA HBO therapy for 2 hours for 20 days and the control group rabbits (n=10) did not receive any corresponding treatment. Osteoblastic activity was evaluated with bone scintigraphy on days 30 and 90. Fracture healing was evaluated by plain radiographs on days 30 and 90. RESULTS: On Day 30, radiological scores were statistically similar in both groups (p=0.167). However, on Day 90, the experimental group displayed significantly higher radiological scores (p<0.001). Osteoblastic activity was also higher in the experimental group on both scintigraphic assessments (p=0.005 and p=0.001). CONCLUSION: The results of this study suggest that HBO can be used as a supplementary therapy in the management of atrophic tibial nonunion.

The comparison of the effect of corticosteroids and platelet-rich plasma (PRP) for the treatment of plantar fasciitis.

INTRODUCTION: In this study, the results of local injection of platelet-rich plasma (PRP) and corticosteroids in the treatment of plantar fasciitis were compared. PATIENTS AND METHODS: Sixty patients who were diagnosed as plantar fasciitis and treated conservatively for at least 3 months and had no response to conservative treatment modalities were involved in this study. The first 30 consecutive patients were treated by local injection of 2 mL of 40 mg Methylprednisolone with 2 mL of 2% prilocaine (metilprednizalone) and the second 30 patients were treated by injecting 3 mL PRP after 2 mL of 2% prilocaine injection. Patients were evaluated according to the modified criteria of the Roles and Maudsley scores and visual analog scale before injection and 3 weeks and 6 months following injection. RESULTS: The mean VAS heel pain scores measured 6 months after treatment were 3.4 in steroid group and 3.93 in PRP group, and the scores in both groups were significantly lower when compared with pretreatment levels (6.2 in steroid group and 7.33 in PRP group). There was no significant difference between steroid and PRP groups in visual analog scale scores and modified criteria of the Roles and Maudsley scores measured at 3 weeks and 6 months (P > 0.05). CONCLUSION: Our results revealed that both methods were effective and successful in treating plantar fasciitis. When the potential complication of corticosteroid treatment was taken into consideration, PRP injection seems to be safer and at least having same effectivity in the treatment of plantar fasciitis.

The patellofemoral kinematics in patients with untreated developmental dislocation of the hip suffering from patellofemoral pain.

PURPOSE: This study reviews the dynamic patellofemoral CT results of 39 patients with untreated developmental dislocation of the hip who are suffering from knee pain. METHOD: The mean age of the patients with unilateral developmental dislocation of the hip was 33.3 (±7.9), for bilateral patients 36.2 (±11.3), and for the control group, it was 31.5 (±8.5). While 14 of them were bilateral, 25 were unilateral. The CT results of 24 asymptomatic adult knees served as the control group. The patellofemoral parameters of patients with unilateral and bilateral developmental dislocation of the hip, the control group's parameters and the effect of femoral anteversion, limb length discrepancy, severity of dislocation, the mechanical axis deviation on patellofemoral parameters were analyzed. RESULTS: In patients with unilateral untreated developmental dislocation of the hip, although the patella was located more laterally at initial flexion degrees, it was located more medially at 30° and 60° flexion with respect to the control group. For the involved extremity, the PTA angles at 15°, 30°, and 60° flexion were significantly higher than in the control group corresponding to medial patellar tilt. In patients with bilateral developmental dislocation of the hip, the course of the patella during tracking in terms of patellar shift was similar to that of the unilateral patients. The amount of leg length discrepancy and the severity of dislocation, as well as the mechanical axis deviation, did not affect the patellofemoral parameters. CONCLUSION: The patients with untreated developmental dislocation of the hip and suffering from knee pain should be analyzed not only for tibiofemoral abnormalities but also for patellofemoral malalignment. LEVEL OF EVIDENCE: Case-control study, Level III.

Factors affecting isokinetic muscle strength before and after anterior cruciate ligament reconstruction.

The purpose of this study was to evaluate the factors affecting muscle strength of ACL-deficient knees before and after ACL reconstruction. The study included 122 male patients who underwent primary ACL reconstruction with a bone-patellar tendon-bone autograft. Preoperative loss and change in muscle strength in both extensor and flexor muscle groups after ACL reconstruction were calculated separately at 60 degrees/sec and 180 degrees/sec angular velocities. We evaluated the effect of surgical delay on the preoperative deficit and on its change after surgery. Muscle strength change after ACL reconstruction was also evaluated in relation to patient compliance to treatment. The longer the delay of ACL reconstruction the more the muscle strength deficit of flexor and extensor muscles increased. In the ACL deficient knees with high strength deficit, improvement in muscle strength was higher after ACL reconstruction for both muscle groups. When delay of ACL reconstruction was short and the patient was compliant to treatment, flexor muscle strength recovery was early. Shortening the delay to reconstruction had a positive influence on muscle strength after ACL reconstruction when preoperative muscle strength deficit was high.

The results of nonoperative treatment for three- and four-part fractures of the proximal humerus in low-demand patients.

OBJECTIVE: To evaluate the results of nonoperative treatment of three- and four-part fractures of the proximal humerus in patients who refused surgery or could not undergo surgery because of medical conditions. DESIGN: Retrospective evaluation of prospective collected data. SETTING: Educational and research hospital. Level IV, therapeutic case series. PATIENTS: Eighteen patients (eight three- and 10 four-part fractures) were included. The mean age was 68.2 ± 13.8 years (range, 39-90 years). The mean follow-up was 39.1 ± 12.4 months (range, 24-60 months). Patients were grouped into two: Group A being younger than 65 years and Group B 65 years or older. INTERVENTION: Standardized nonoperative treatment and follow-up protocols were used. MAIN OUTCOME MEASUREMENTS: Functional and radiographic assessments were performed in posttreatment first year and at latest follow-up. Constant-Murley scores were also obtained for both shoulders. RESULTS: The mean Constant-Murley score was 61.3 ± 13.5 (range, 40-85) at latest follow-up. Osteonecrosis was detected in five patients. All patients had significantly lower SF-36 scores for all subscales except mental health than the normal Turkish population. There was no significant difference between three- and four-part fractures regarding age and Constant-Murley scores. The mean Constant-Murley score of the Group A patients with three-part fractures was significantly higher when compared with the Group A patients with four-part fractures. There was no significant difference between patients with and without osteonecrosis regarding fracture types or the Constant-Murley scores at the latest follow-up. CONCLUSIONS: Although the individual fracture type does not have an influence on functional results, these results are better in patients younger than 65 years with three-part fractures. The results of the nonoperative treatment of these fractures are satisfactory even in elderly patients. The radiographic appearances did not correspond with the functional results.

Normophosphatemic type tumoral calcinosis associated with chronic recurrent multifocal osteomyelitis: a case report.

Chronic recurrent multifocal osteomyelitis (CRMO) and tumoral calcinosis are two distinct musculoskeletal diseases with unclear etiopathogenesis. Previously, two CRMO cases with associated tumoral calcinosis were reported. We report a patient who developed tumoral calcinosis after the surgical treatment of CRMO. To our knowledge it is the third patient in whom tumoral calcinosis developed sporadically during follow-up for CRMO.

The effects of leukotriene receptor antagonist montelukast on histological, radiological and densitometric parameters of fracture healing.

OBJECTIVES: In this study we evaluated the effects of montelukast, a leukotriene-receptor antagonist, on fracture healing, and investigated the hypothesis that enhanced fracture healing would be observed with montelukast in a rat tibia fracture model. MATERIALS AND METHODS: Sixty adult (6 months old) female Wistar albino rats (mean weight 220 g, range 210-270 g) were randomly divided into two groups: a montelukast group (n=30) and a control group (n=30). Closed tibia fractures were created and fixed by intramedullary Kirschner wire. The rats were sacrificed three and six weeks after the fractures. Radiological and histological evaluations were performed, and bone mineral density was measured. RESULTS: Three rats died in the montelukast group, whereas only one died in the control group during the study. Initial weight and weight gain at the 3rd and 6th weeks were not significantly different between the groups (p>0.05). Bone mineral densities in the control and study groups were 0.13±0.009 gr/cm2, and 0.13±0.01 gr/cm2 at week three and 0.16±0.02 gr/cm2, and 0.13±0.01 gr/cm2 at week six, respectively. Histopathological scores in the control and study groups were 3.42±0.6, and 3.0±0.0 at week three and 3.5±0.5, and 3.4±0.8 at week six, respectively. Radiological scores in the control and study groups were 1.19±0.6, and 1.0±0.6 at week three and 3.0±0.8, and 2.9±0.9 at week six, respectively. There were no significant differences between the two groups in any parameters evaluated at either time interval (p>0.05). CONCLUSION: Our study failed to show a possible positive effect of leukotriene receptor inhibition on fracture healing at the 3rd and 6th postoperative weeks.

Plasma vascular endothelial growth factor levels are similar in subjects with and without osteoporosis.

OBJECTIVES: The relation between serum vascular endothelial growth factor (VEGF) level and bone mineral density (BMD) value was evaluated to investigate the role of VEGF at etiopathogenesis of the osteoporosis. PATIENTS AND METHODS: Bone scanning with dual energy X-ray absorptiometry (DEXA) was performed on a total of 276 patients more than 40 years of age between September 2007 and January 2008 in our hospital's radiology department. A total of 88 patients (44 females; mean age 62.8+/-12.2 year, 44 males; mean age 58.7+/-12.1 year) meeting the study criteria were included. These patients formed four groups; osteoporotic male patients (group MO, n=22, BMD< -2.5), normal males (group MN, n=22, BMD> -1), osteoporotic female patients (group FO, n=22, BMD< -2.5), and normal females (group FN, n=22, BMD> -1). Bone mineral density measurements were performed with DEXA. Serum VEGF level was determined by the endogenous human ELISA kit. The relationships between body mass index (BMI), age, BMD and serum VEGF levels were analyzed. RESULTS: The difference between male and female participants in terms of serum VEGF levels was not statistically significant (p>0.05). The differences in terms of mean VEGF values between the MO and MN groups and the FO and FN groups were not statistically significant (p>0.05). In MN cases, BMD was negatively correlated with VEGF levels (p<0.05). In MO group, the correlation between BMD and serum VEGF levels was not statistically significant (p>0.05). CONCLUSION: Although the plasma levels of osteoporotic subjects are relatively higher than in the normal groups, this was not statistically significant in either male or female subjects. The small sample size could be a reason for this insignificance. The negative correlation between serum VEGF and BMD levels in the MN group was not present in the MO group. When the various effects of serum VEGF on bone metabolism are taken into account, to clarify the pathophysiology of male osteoporosis, this association between BMD values and VEGF in male population must be investigated in further studies.

Bilateral simultaneous femoral neck fractures secondary to a post-infarct generalized tonic-clonic seizure. A case report.

Bilateral femoral neck fractures are generally associated with high-energy trauma or defects in bone metabolism. We present a patient who had not been subjected to high-energy trauma and in whom there was no bone metabolism disorder.

Role of pathophysiology of patellofemoral instability in the treatment of spontaneous medial patellofemoral subluxation: a case report.

INTRODUCTION: Medial patellar subluxation is usually seen after lateral retinacular release. Spontaneous medial subluxation of the patella is a very rare condition. There are few reports in the literature on the pathophysiology of iatrogenic medial patellar subluxation. To our knowledge, there are no reports of the pathophysiology of non-iatrogenic medial patellar subluxation in the English literature. In this study we present a case of spontaneous medial patellar instability that is more prominent in extension during weight bearing. We also try to define the treatment protocol based on pathophsiology. CASE PRESENTATION: We report the case of a 21-year-old Turkish man with spontaneous medial patellar instability. He had suffered right knee pain, clicking and popping sensation in the affected knee for three months prior to presentation. Clinical examination demonstrated medial patellar subluxation that is more prominent in extension during the weight bearing phase of gait and while standing. Increased medial tilt was observed when the patella was stressed medially. Conventional anterior to posterior, lateral and Merchant radiographs did not reveal any abnormalities. After three months of physical therapy, our patient was still suffering from right knee pain which disturbed his gait pattern. Throughout the surgery, medial patellar translation was tested following the imbrication of lateral structures. He still had a medial patellar translation that was more than 50% of his patellar width. Patellotibial ligament augmentation using an iliotibial band flap was added. When examined after surgery, the alignment of the patella was effectively corrected. CONCLUSIONS: Chronic imbalance between the strengths of vastus lateralis and vastus medialis results in secondary changes in passive ligamentous structures and causes additional instability. Physical therapy modalities that aim to strengthen the vastus lateralis might be sufficient for the treatment of spontaneous medial instability. There would be no need for any surgical intervention if spontaneous medial instability was recognized before the additional instability occured. If necessary, lateral imbrication followed by lateral patellotibial ligament augmentation can be performed, and these would effectively correct spontaneous medial patellofemoral instability.

Single or double distal locking in intramedullary nailing of tibial shaft fractures: a prospective randomized study.

BACKGROUND: The number of distal locking screws may have an effect on union, complication rates and operation time. The purpose of this study was to determine the effect of one or two distal locking screws in unreamed intramedullary nailing of closed or grade 1 open, simple or wedge tibial shaft fractures on the incidence of malunion, delayed union, non-union, and screw failure. METHODS: Fifty-seven patients (39 male, 18 female; mean age 38.5+/-10.7 years) were randomized to two groups as either one or two distal locking screws and were evaluated prospectively for the incidences of malunion, delayed union, non-union, and screw failure. Twenty-nine patients were included in the two distal screws group and 28 patients in the single distal screw group. Groups were then subdivided to end fractures (proximal+distal end fractures) or mid-shaft fractures and reevaluated for the incidences of complications. Mann-Whitney U, chi-square and T tests were used for statistical analysis. RESULTS: Mean follow-up was 2.4 years (range, 1.5-4.7 years). There was no case of malunion in either group. The incidences of delayed union, non-union or screw failure were not different (p>0.05). However, complication rate for end fractures in the two screw group was higher than that in the one screw group (p:0.04). CONCLUSION: For non-complex, closed or grade 1 open tibial shaft fractures, locking of an intramedullary nail with a single distal screw is safe, and may help to decrease operation time and radiation exposure.