A new method for reduction quality assessment in acetabular fractures: acetabular congruency measurement.

INTRODUCTION: The determination of adequate reduction is difficult perioperatively due to inadequate radiographic scanning and objective measurement methods. The purpose of the present study is to evaluate an objective measurement of the weight bearing acetabular dome congruency. The sensitivity and specificity of 2 measurement methods after acetabular fracture fixation are compared. PATIENTS AND METHODS: Postoperative acetabular reduction was assessed based on postoperative anteroposterior radiographs according to hip joint congruency and Matta's classification in 55 patients. For hip joint congruency measurements, one circle was drawn as superior femoral head border and another one was drawn as weight-bearing acetabular dome border. The difference between the centres of the circles was measured in millimetres. Comparative studies were performed between groups according to reduction quality and clinical and radiological results. RESULTS: The threshold value for the difference between the 2 circle centres was found as 4.4 mm according to the clinical outcomes; 3.8 mm according to radiological outcomes in joint congruency method. The sensitivity of this method was found as 90.2% and 92.7%, and specificity as 64.3% and 57.1% considering the clinical and radiological results, respectively. In the assessment of joint congruency, false positive rate was lower than assessing reduction quality using the method defined by Matta. CONCLUSIONS: Joint congruency assessment based on a postoperative anteroposterior radiograph in patients treated with open reduction internal fixation for acetabular fractures is a suitable method for assessing the adequacy of reduction. This method can be used intraoperatively using fluoroscopy imaging during surgery.

Lateral Transfibular Approach to Tibial Pilon Fractures: A Case Report.

We present a case of tibial pilon fracture where only the lateral part of the distal tibia was affected. The transfibular approach to the ankle was used for the surgical treatment of the fracture. After an initial nonweightbearing period of 3 weeks, full weightbearing was allowed 8 weeks after surgery. The second-year follow-up showed no evidence of degenerative signs, with full ankle range of motion.

Posterior Malleolus Fractures in Trimalleolar Ankle Fractures: Malleolus versus Transyndesmal Fixation.

BACKGROUND: In ankle fractures involving the posterior malleolus, the issue of which types of fractures require posterior malleolus fixation is still controversial. Recent studies have demonstrated that trimalleolar fractures adversely affect the functional outcomes in comparison to bimalleolar fractures of the lateral and medial malleolus. The purpose of this study was to assess the effects of posterior malleolus fixation on the functional and radiological outcomes. MATERIALS AND METHODS: Reduction quality, development of posttraumatic ankle osteoarthritis, and functional outcomes in 49 consecutive trimalleolar ankle fractures were evaluated retrospectively in patients with and without posterior malleolus fixation. Group I consisted of 29 patients, in which posterior malleolar fracture was left untreated. Twenty patients in Group II, posterior malleolar fragment was fixed directly by screws alone or plate screw. Twenty-one of these 49 patients were male (43%). The mean age was 47 years (range 20-82 years). RESULTS: The mean followup was 12 to 51 months with a mean of 15 months (range 12-51 months). Statistically significant differences were found between Group I and Group II in terms of ankle arthrosis. American Orthopaedic Foot and Ankle Society score was significantly lower in Group I compared to Groups II. CONCLUSIONS: These results demonstrate that posterior malleolar fracture fixation is closely related to successful radiological and functional outcomes after trimalleolar fractures. Transyndesmal screw fixation may not be needed in the cases where the posterior malleolar fracture fixated. For these reasons, we recommend that all posterior malleolar fractures have to be fixed regardless of size.

ASSOCIATED POSTERIOR PELVIC INJURY PATTERNS IN TRANSVERSE-ORIENTED ACETABULAR FRACTURE.

OBJECTIVE: Our study analyzed the incidence of posterior pelvic injury patterns and their influence on the surgical treatment of transverse-oriented acetabular fractures . METHODS: Fifty-one transverse-oriented acetabular fracture cases admitted between 1999 and 2013 were evaluated retrospectively. Comparative studies were performed for groups organized by acetabular fracture type, degree of sacroiliac separation, and postoperative reduction quality . RESULTS: Associated posterior pelvic injuries were found in 34 (66.7%) of the 51 patients. There were 32 sacroiliac separations in the 34 patients with associated posterior pelvic injury, and ipsilateral sacroiliac separations were more frequent in this subgroup. Measurements guided by computerized tomography showed that 16 sacroiliac separations were ≤0.5 cm (mean=0.43±0.14 cm), 10 were 0.5-1 cm (mean=0.73±0.17 cm), and the remaining 6 were >1 cm (mean=1.55±0.15 cm). In the group of 34 patients with associated posterior pelvic injury, acetabular reduction was anatomic in 19 (55.9%) patients, imperfect in 10 (29.4%) patients, and poor in 5 (14.7%) patients. For isolated acetabular fractures, reduction rates were as follows: 12 (70.6%) anatomic, 3 (17.6%) imperfect, and 2 (11.8%) poor. The rate of anatomic reduction was significantly higher when sacroiliac separation was ≤0.5 cm (p=0.027) . CONCLUSION: Associated posterior pelvic injuries, especially ipsilateral sacroiliac joint separation, accompany most transverse-oriented acetabular fractures and may influence the quality of acetabular reduction. Level of Evidence III, Therapeutic Studies Investigating the Results of Treatment.

OBJETIVO: Nosso estudo analisou a incidência de padrões de lesão pélvica posterior e sua influência no tratamento cirúrgico das fraturas do acetábulo com orientação transversal. MÉTODOS: Cinquenta e um casos de fratura acetabular com orientação transversal foram avaliados retrospectivamente entre 1999 e 2013. Foram realizados estudos comparativos para grupos formados de acordo com o tipo de fratura acetabular, grau de separação sacroilíaca e qualidade da redução no pós-operatório. RESULTADOS: Constataram-se lesões pélvicas posteriores associadas em 34 (66,7%) dos 51 pacientes. Havia 32 separações sacroilíacas nos 34 pacientes com lesão pélvica posterior associada, e as separações sacroilíacas ipsilaterais foram mais frequentes nesse subgrupo. De acordo com medições guiadas por tomografia computadorizada, 16 separações sacroilíacas foram ≤ 0,5 cm (média = 0,43 ± 0,14 cm), 10 estavam entre 0,5 e 1 cm (média = 0,73 ± 0,17 cm) e os 6 restantes foram >1 cm (média = 1,55 ± 0,15 cm). No grupo de 34 pacientes com lesão pélvica posterior, a redução acetabular foi anatômica em 19 (55,9%) pacientes, imperfeita em 10 (29,4%) pacientes e deficiente em5 (14,7%) pacientes. Nas fraturas acetabulares, as taxas de redução foram as seguintes: 12 (70,6%) anatômicas, 3 (17,6%) imperfeitas e 2 (11,8%) deficientes. A taxa de redução anatômica foi significativamente maior quando o grau de separação sacroilíaca foi ≤ 0,5 cm (p = 0,027). CONCLUSÃO: As lesões pélvicas posteriores associadas, especialmente a separação da articulação sacroilíaca ipsilateral, acompanham a maioria das fraturas do acetábulo com orientação transversal e podem influenciar a qualidade da redução acetabular. Nivel de Evidência III, Estudos Terapêuticos - Investigação dos Resultados do Tratamento.

The Central Dislocation of Femoral Head in the Transverse and Both Column Acetabular Fractures: Is It Really Medialized?

PURPOSE: We hypothesized that the central dislocation of the femoral head does generally not occur in transverse acetabular fractures, although it does usually occur in both column fractures. MATERIALS AND METHODS: Fifty-two transverse and both column acetabular fracture cases were evaluated retrospectively. The distances between (a) the sciatic notch on the fracture side and the vertical axis of the pelvis (VA line) and (b) the contralateral intact sciatic notch and the VA line were measured. The a/b ratio corresponded to the superior iliac segment displacement or rotation. The ratio of the distance between the fracture side femoral head and the VA line (c) and the distance between the contralateral intact femoral head and the VA line (d) corresponded to the femoral head displacement. The width of ischium (e) on fractured side and (f) contralateral side were measured. The e/f ratio increment reflected ischiadic fragment mobility. RESULTS: The median value of femoral head displacement (c/d) of the transverse fracture group (n=25) was 1.02 (1.000-1.07). Ischiadic fragment rotation (e/f ratio) of the transverse fracture group was 1.000. The median value of femoral head displacement (c/d) of the both column fractures (n=27) was 0.78 (0.64-0.85). Ischiadic fragment rotation (e/f ratio) of the both-column group was 1.15 (1.06-1.23). The differences between groups according to measurements were statistically significant. CONCLUSION: In contrary to Letournel description, our findings showed no medialization of femoral head in transverse acetabular fractures in general. This might be an illusion resulting from external rotation of the superior iliac segment.

Are the Sensory Fibers of the Ulnar Nerve Affected in Carpal Tunnel Syndrome?

PURPOSE: Distribution of paresthesia throughout the skin area without median nerve innervation is frequently seen in carpal tunnel syndrome (CTS). However, its pathophysiologic mechanisms are still unclear. We aimed to research whether a dysfunction in sensory fibers of the ulnar nerve (UN) was present or not in hands with CTS. METHODS: Totally, upper extremity nerve conduction study recordings of 508 patients were considered. After exclusions, 331 upper extremity recordings of 277 patients were included. We compared the results of sensory conduction studies of median nerve and UN between normal hands and hands with CTS. RESULTS: The mean distal sensory latency of the median nerve was longer, the mean conduction velocity was slower, and mean nerve action potential amplitude was higher in the hands with CTS than in normal hands (P < 0.001 for all comparisons). There was no statistically significant difference on any sensory conduction parameters of UN recorded on digit IV or digit V between the disease and control groups (P > 0.05 for all comparisons). The rates of conduction abnormalities of the UN sensory fibers were also similar in hands with CTS and in normal hands (P > 0.05 for all comparisons). CONCLUSIONS: The hands with CTS do not have an increased rate of conduction abnormalities of UN sensory fibers compared with the normal hands in our study population. Therefore, our study did not confirm the distortion of UN sensory fibers as a mechanism underlying the spread of paresthesia throughout the skin area without median nerve innervation in CTS.

Associated posterior pelvic injury patterns in transverse-oriented acetabular fracture / Padrões de lesão pélvica posterior associada em fratura acetabular com orientação transversal

ABSTRACT Objective: Our study analyzed the incidence of posterior pelvic injury patterns and their influence on the surgical treatment of transverse-oriented acetabular fractures . Methods: Fifty-one transverse-oriented acetabular fracture cases admitted between 1999 and 2013 were evaluated retrospectively. Comparative studies were performed for groups organized by acetabular fracture type, degree of sacroiliac separation, and postoperative reduction quality . Results: Associated posterior pelvic injuries were found in 34 (66.7%) of the 51 patients. There were 32 sacroiliac separations in the 34 patients with associated posterior pelvic injury, and ipsilateral sacroiliac separations were more frequent in this subgroup. Measurements guided by computerized tomography showed that 16 sacroiliac separations were ≤0.5 cm (mean=0.43±0.14 cm), 10 were 0.5-1 cm (mean=0.73±0.17 cm), and the remaining 6 were >1 cm (mean=1.55±0.15 cm). In the group of 34 patients with associated posterior pelvic injury, acetabular reduction was anatomic in 19 (55.9%) patients, imperfect in 10 (29.4%) patients, and poor in 5 (14.7%) patients. For isolated acetabular fractures, reduction rates were as follows: 12 (70.6%) anatomic, 3 (17.6%) imperfect, and 2 (11.8%) poor. The rate of anatomic reduction was significantly higher when sacroiliac separation was ≤0.5 cm (p=0.027) . Conclusion: Associated posterior pelvic injuries, especially ipsilateral sacroiliac joint separation, accompany most transverse-oriented acetabular fractures and may influence the quality of acetabular reduction. Level of Evidence III, Therapeutic Studies Investigating the Results of Treatment.

RESUMO Objetivo: Nosso estudo analisou a incidência de padrões de lesão pélvica posterior e sua influência no tratamento cirúrgico das fraturas do acetábulo com orientação transversal. Métodos: Cinquenta e um casos de fratura acetabular com orientação transversal foram avaliados retrospectivamente entre 1999 e 2013. Foram realizados estudos comparativos para grupos formados de acordo com o tipo de fratura acetabular, grau de separação sacroilíaca e qualidade da redução no pós-operatório. Resultados: Constataram-se lesões pélvicas posteriores associadas em 34 (66,7%) dos 51 pacientes. Havia 32 separações sacroilíacas nos 34 pacientes com lesão pélvica posterior associada, e as separações sacroilíacas ipsilaterais foram mais frequentes nesse subgrupo. De acordo com medições guiadas por tomografia computadorizada, 16 separações sacroilíacas foram ≤ 0,5 cm (média = 0,43 ± 0,14 cm), 10 estavam entre 0,5 e 1 cm (média = 0,73 ± 0,17 cm) e os 6 restantes foram >1 cm (média = 1,55 ± 0,15 cm). No grupo de 34 pacientes com lesão pélvica posterior, a redução acetabular foi anatômica em 19 (55,9%) pacientes, imperfeita em 10 (29,4%) pacientes e deficiente em5 (14,7%) pacientes. Nas fraturas acetabulares, as taxas de redução foram as seguintes: 12 (70,6%) anatômicas, 3 (17,6%) imperfeitas e 2 (11,8%) deficientes. A taxa de redução anatômica foi significativamente maior quando o grau de separação sacroilíaca foi ≤ 0,5 cm (p = 0,027). Conclusão: As lesões pélvicas posteriores associadas, especialmente a separação da articulação sacroilíaca ipsilateral, acompanham a maioria das fraturas do acetábulo com orientação transversal e podem influenciar a qualidade da redução acetabular. Nivel de Evidência III, Estudos Terapêuticos - Investigação dos Resultados do Tratamento.

The relation between elbow range of motion and patient satisfaction after open release of stiff elbow.

OBJECTIVE: The aim of this retrospective study was to find out whether a cut off value existed for elbow flexion and extension after open surgical release of elbow contracture that would correlate with subjective patient satisfaction. METHODS: The study enrolled 77 patients (53 males and 24 females with a mean age of 35.1 (18-77) years at the time of operation) with elbow contracture who attended regular follow-up appointments for more than 12 months. The mean follow up period was 44.2 months (12-186). The preoperative and postoperative modified MAYO elbow scores, objective parameters of increase in both flexion and extension end point measurements and improvement in total ROM were compared in order to determine the cut off degree of ROM in both flexion and extension that significantly correlated with patient satisfaction. RESULTS: Of the 77 participating patients, 26 patients had an extrinsic (33.8%) and 51 patients had an intrinsic elbow contracture (66.2%). Surgeries performed involved 40 cases of lateral release and 37 cases of both lateral and medial (progressive) release. The median preoperative total flexion-extension arch (ROM) was 45° (20°-65°). The median postoperative total flexion-extension arch (ROM) was 110° (97.5°-125°). The modified MAYO elbow score improved from 60 to 85 points postoperatively. The postoperative flexion cut off value was 115° for an excellent or good postoperative modified MAYO elbow score. CONCLUSION: Post-operative flexion cut off value was 115° and had a positive effect on the postoperative patient satisfaction. The cut off value for postoperative extension was 20° but it was not a significant variable on patient satisfaction as was the total increase in ROM. LEVEL OF SIGNIFICANCE: Level IV Therapeutic Study.

Does the comparison of median-to-ulnar nerve sensory conduction add an additional value in electrodiagnosis of carpal tunnel syndrome?

BACKGROUND AND PURPOSE: Distal sensory onset latency (DSOL), conduction velocity (SCV) and nerve action potential (SNAP) amplitudes are used in electrodiagnosis of carpal tunnel syndrome (CTS) beside motor conduction data. The aim of our study is to search whether the comparison of median-to-ulnar nerve sensory conduction adds an additional diagnostic value in CTS or not. METHODS: Median and ulnar nerve were stimulated on wrist, and SNAPs were recorded on second and fifth fingers, respectively. Best cut-off points for the searched parameters and their diagnostic efficiencies were determined. The cut off points were also stratified according to the age and gender, and their diagnostic efficiencies were calculated again. RESULTS: The study includes 415 hands belong to 344 subjects. Best cut off points for median nerve DSOL and SCV were 2.7 msec and 49.0 m/sec with the diagnostic efficiencies of 87.7% and 88.7%, respectively. Best cut off points for DSOL difference and SCV difference were 0.62 msec and 4.0 m/sec, and efficiencies were 89.6% and 84.3%, respectively. CONCLUSION: Determining the relative elongation of median nerve DSOL to the ulnar nerve one has a little additional value in electrodiagnosis of CTS, whereas any additional value is not obtained from SCV comparison.

Proximal row carpectomy for Lichtman stage III Kienböck's disease.

OBJECTIVE: The purpose of this study was to investigate the objective and subjective outcomes of proximal row carpectomy (PRC) for stage III Kienböck's disease and determine if the physician's objective measurements correlate with the patients' subjective outcomes. METHODS: Twenty-four patients who underwent PRC for stage III Kienböck's disease with a follow-up period of more than 18 months were enrolled in the study. Clinical evaluation included preoperative and postoperative Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) questionnaire, postoperative Mayo wrist score, postoperative total joint range of motion (ROM), as well as grip and pinch strength measurements of the operated and normal side. Radiographic criteria such as carpal height ratio, subchondral cyst, and osteophyte formation were assessed during the follow-up period. Mean follow-up period was 41.7 months (range: 18-106 months). RESULTS: No wrists underwent total arthrodesis. Reflex sympathetic dystrophy was observed in 2 patients (8.3%). Postoperative ROM measurements, power grip, and pinch strength values significantly decreased in both stages (IIIA and IIIB) on the operated side compared to the normal side. In contrast, Q-DASH scores significantly increased in both stages compared to preoperative values. Average Mayo wrist score was 67.3 (range: 10-90). CONCLUSION: PRC is a well-tolerated procedure for stage III Kienböck's disease with certain complications. While subjective values improved significantly, there was no correlation between this improvement in subjective values and objective measurements. PRC was not able to restore motion postoperatively to that of the normal side, even though this feature did not affect postoperative subjective patient satisfaction.

Bilateral Femoral Neck Fatigue Fracture due to Osteomalacia Secondary to Celiac Disease: Report of Three Cases.

Bilateral non traumatic femoral neck fatigue fracture is a rare condition usually occurring secondary to medical conditions such as pregnancy, pelvic irradiation, corticosteroid exposure, chronic renal failure and osteomalacia. In this report, we present three young female patients with bilateral femoral neck fracture secondary to osteomalacia. The underlying cause of osteomalacia was Celiac disease in all patients. The patients were treated with closed reduction and internal fixation with cannulated lag screws. They were free of pain and full weight bearing was achieved at three months. There were no complications, avascular necrosis and nonunion during the follow up period. In patients with bone pain, non traumatic fractures and muscle weakness, osteomalacia should be kept in mind and proper diagnostic work-up should be performed to identify the underlying cause of osteomalacia such as celiac disease.

Distal fusion level selection in Lenke 1A curves according to axial plane analyses.

BACKGROUND CONTEXT: In adolescent idiopathic scoliosis (AIS), identification of curve patterns and determination of fusion levels are most important for correcting deformity, improving trunk balance, and saving motion segments. Lenke 1A scoliosis is the most common type of AIS, accounting for around 16% of all AIS; however, how to determine the lower instrumented vertebrae in this common curve type is unclear. PURPOSE: The aim was to classify Lenke 1A curves according to lumbar axial plane analyses to determine optimal distal fusion level selection. STUDY DESIGN: This was a retrospective study. PATIENT SAMPLE: This study included 69 consecutive patients with AIS (13 males and 56 females) of Lenke Type 1A curve who underwent posterior correction and fusion of the thoracic spine between 2001 and 2013 in a single center. OUTCOME MEASURES: Coronal, sagittal, and axial parameters were measured from plain radiographs that were obtained at initial medical examination of the patients. METHODS: Coronal and sagittal plane and whole spine segmental vertebra rotations from thoracic 1 to lumbar 5 were evaluated by using Drerup method. As a result of analysis of axial plane, all patients with Lenke 1A curves were divided into three groups depending on lumbar vertebral rotation. In Group I, the rotation of lumbar vertebral rotation was accepted as neutral. In Group II, the direction of lumbar vertebral rotation was same with other vertebrae in the main curve. In Group III, the rotation of lumbar vertebral rotation had opposite direction with vertebrae in the main curve. RESULTS: In Group I curves, the mean position of lower end vertebrae (LEVs) was more frequently at T11, neutral vertebra (NV)-last touched vertebra (LTV) at T12, and stable vertebra (SV) at L2. In Group II curves, the mean position of LEV was more frequent at L1, LTV at L2, NV at L3, and SV at L4, whereas in Group III curves, the median position of LEV-NV-LTV was frequently at T12 and that of SV at L1. Then, Group I to III curves between Group II curves showed the gap differences of NV-LEV, SV-LEV to be significantly different. Similarly, the SV was not more than two segments distal from LEV in Group I and Group III but more than two to three segments from LEV in Group II. CONCLUSIONS: Our analysis suggested that not all Lenke 1A curves yield satisfactory outcome with the same fusion extend although a high percentage of the patients with Lenke 1A curves have shown satisfactory outcome with NV fusion. Thus, it seems that some Lenke 1A curves may require fusion to SV.

Surgical treatment of thoracolumbar tuberculosis: a retrospective analysis of autogenous grafting versus expandable cages.

PURPOSE: There has been no uniform and extensive description of the use of expandable cages in the setting of thoracolumbar tuberculosis. The purpose of the study was to evaluate the results of the expandable cages and compare with autogenous strut grafting in thoracolumbar tuberculosis. METHODS: From January 2003 to January 2014, a total of 28 patients with thoracolumbar tuberculosis were treated surgically in our medical center. Patients were divided into three groups. 17 patients received anterior-only surgery; consisting of autogenous iliac bone grafting only in 9 (Group 1), grafting with anterior screw-rod system instrumentation after debridement in 8 patients (Group 2). 11 patients underwent anterior surgery including debridement and distraction of the kyphosis by cages after corpectomy following posterior instrumentation (Group 3).The changes in degree of kyphotic deformity, loss of correction, intervertebral height and loss of intervertebral height were evaluated preoperatively, postoperatively and at the final follow-up. RESULTS: Patients were followed 52 ± 10.7 months (range, 18-120 months). Mean age in the Group 1 was 42 (18-69) years, 62 (19-86) years in the Group 2 and 51 (19-71) years in the Group 3. There was no statistically significant difference (P > 0.05) in the focal kyphosis preoperatively, postoperatively and at the last follow-up between three groups. There were statistically significant differences (P < 0.05) in loss of correction, intervertebral height (preoperative, postoperative and final follow-up) and loss of intervertebral height between three groups. There was a greater loss of correction in Group 1 when compared with Group 2 and Group 3. The difference was statistically significant (p < 0.001). There was no statistically significant difference in the intervertebral height postoperatively and follow-up between Group 1 and Group 2. There was a significant increase in the intervertebral height in Group 3 when compared with Group 1 and Group 2. There was also a significant increase in the intervertebral height in Group 2 when compared with Group 1. There was a greater loss of intervertebral height in Group 1 than in Group 2 and Group 3. The difference was statistically significant (p < 0.001). CONCLUSIONS: Expandable cages are an acceptable surgical option for the treatment of thoracolumbar tuberculosis. Sagittal alignment is better prevented with the expandable cages than anterior grafting with or without anterior instrumentation. Subsidence of the expandable cages is not uncommon and results in the loss of Cobb angle correction and intervertebral height. However, anterior vertebral column reconstruction by expandable cages provides a very high and effective rate of deformity correction and maintenance.

External rotator sparing with posterior acetabular fracture surgery: does it change outcome?

This study analyses the results of the treatment with external rotator sparing approach in acetabular fractures to determine whether muscle sparing has a positive impact on functional outcome. 20 patients with a mean age of 45.9 years (range: 26-64) that had been treated for displaced acetabular fractures were included in this series. Short Musculoskeletal Function Assessment (SMFA) questionnaire and hip muscle strength measurement were done at the 24-month of follow-up period. The radiographic results at the final followup were excellent in 9 hips (45%), good in 6 hips (30%), fair in 4 hips (20%), and poor in one hip (5%) according to the criteria developed by Matta. The average SMFA score for all of the patients was 18.3 (range: 0-55.4). The mean dysfunctional and bother indexes were 17.2 and 20.6, respectively. The overall muscle strength deficit was 11.8%. The greatest loss of strength was in internal rotation. In patients with better postoperative reduction quality of acetabular fracture, peak torque, and maximum work of hip flexion, extension and also internal rotation maximum work deficit were significantly lower (P < 0.05). Accurate initial reduction and longer postoperative muscle strengthening exercise programs seem critical to decrease postoperative hip muscle weakness after acetabular fractures.

Mesenchymal stem cell application improves tendon healing via anti-apoptotic effect (Animal study).

OBJECTIVE: The aim of this study was to determine the effects of mesenchymal stem cell (MSC) application and the possible pathways of MSC's effects on tendon strength and healing after tendon repair. METHODS: The study included 40 Wistar albino rats. Mesenchymal stem cells were obtained from the femurs and tibias of 6 rats. Achilles tendons of the remaining 34 rats were cut and repaired with open surgical procedures. Rats were divided into 2 groups. Percutaneous MSCs were applied to the study group (n=17) and physiological serum only was applied to the control group (n=17) at the 4th week. Rats were sacrificed using the cervical dislocation method under ether anesthesia at the 12th week and samples were analyzed by histological and immunohistochemical methods. For biomechanical analysis, a traction force was applied at 10 mm/min and load to failure was recorded for each specimen in Newtons. RESULTS: Histologically, there was no significant difference between groups (p>0.05). In the immunohistochemical studies, MSCs were located more intensively at the repair zone. Apoptosis was minimally present in the study group and was clearly increased in the control group. Increase in tendon strength was significantly higher in the study group than in the control group at the 12th week (p<0.05). CONCLUSION: The application of MSCs to decrease re-ruptures has a positive effect on tendon strength, probably due to their anti-apoptotic effects. Mesenchymal stem cell application can be used percutaneously and is effective in clinical practice in the late stages of tendon healing.

Management of acetabular fractures with modified posterior approach to spare external hip rotators.

INTRODUCTION: In the present study the quality of reduction and incidence of complications in hip external rotator sparing modified posterior approach was assessed in both simple and complex acetabular fractures. MATERIALS AND METHODS: This retrospective study includes 37 patients (38 hips) with a mean age of 42.1 years (range 21-60), that had been treated for displaced acetabular fractures from June 2007 through May 2011. They were reviewed at a mean of 3 years (20-67 months). RESULTS: The fractures were classified according to the Letournel-Judet classification. Anatomic reduction and stable fixation of the fracture with less than 2mm residual displacement was achieved in 28 of 38 hips. At the final follow up the patients were evaluated clinically according to Merle d'Aubigne and Postel scoring system which had been modified by Matta and radiologically based on the criteria described by Matta. The clinical results were excellent in 20, good in 8, fair in 8, and poor 2 hips. Complications included two superficial local wound infection and 10 heterotopic ossification with 7 of the cases having grade I heterotopic ossification. Avascular necrosis of the femoral head was not seen in any of the 38 hips. One patient with preoperative sciatic nerve palsy had complete recovery of neurologic function. There were no cases of deep vein thrombosis or pulmonary embolism. CONCLUSION: The functional outcome was satisfactory in most of the cases and comparable with other larger series. Using the limited part of Henry's sciatic nerve exposure skin incision - working in the plane between gluteus maximus and the tensor fascia lata as in the classical Gibson approach and two portal external rotator hip sparing approach resulted in good fracture reduction without approach related complications.

Golden bullet-denosumab: early rapid response of metastatic giant cell tumor of the bone.

Giant cell tumor of the bone (GCTB) is usually a benign, locally aggressive tumor with metastatic potential. Histogenesis of GCTB is unknown and a correlation has not been found between histologic and clinical course. For this reason, many authors consider its prognosis unpredictable. Lung metastasis after GCTB treatment is well known and generally has unfavorable outcome, despite varied chemotherapy regimens. Denosumab, which inhibits RANK-RANKL interaction, is a new, promising actor among targeted therapeutic agents for GCTB. In this report, we emphasize on early rapid response to denosumab in metastatic GCTB.

Percutaneous fixation of anterior column acetabular fracture in a renal transplant recipient.

Renal transplantation, performed per million population, ranges from 30 to 60 in developed countries. The transplanted kidney is generally placed in iliac fossa; therefore the treatment procedure of the pelvic trauma in these patients should be selected carefully. The gold standard technique for the treatment of displaced acetabulum fractures is open reduction and internal fixation. Our patient had received a living-related-donor renal transplant due to chronic renal failure. In the second year of transplantation, she had been injured in a motor-vehicle accident, and radiographs showed a right acetabular anterior column fracture and left pubic rami fractures. The patient was treated with percutaneous fixation techniques and at one year of postoperative period there was no evidence of degenerative signs and the clinical outcome was good. Beside having the advantage of avoiding dissection through the iliac fossa by the standard ilioinguinal approach, percutaneous techniques, with shorter surgical time, decreasing soft tissue disruption, and the potential for early discharge from hospital might be ideal for a renal transplant recipient carrying a higher risk of infection. Percutaneous fixation of selected acetabular fractures in a renal transplant recipient would presumably have the potential to decrease the morbidity associated with traditional open surgical procedures.

Bilateral carpal tunnel syndrome in a 9-year-old boy with acromicric dysplasia.

Acromicric dysplasia is a skeletal dysplasia that is characterized by short stature, short hands and feet, typical facial dysmorphism, normal mental development, and characteristic hand radiology. Carpal tunnel syndrome may be seen in adults with acromicric dysplasia; however, to the authors' knowledge, it has not been reported in pediatric patients. This article describes a 9-year old boy with bilateral carpal tunnel syndrome and acromicric dysplasia treated operatively. No recurrences occurred during 1 year of postoperative follow-up.Carpal tunnel syndrome is a rare disease in childhood. The etiologic factors of carpal tunnel syndrome include trauma (especially distal radius epiphysealis), overuse, genetic or metabolic disorders, space-occupying lesions in the carpal tunnel, hemophilia, congenital anomalies, adverse effect of growth hormone replacement therapy, and idiopathic carpal tunnel syndrome. Acromicric dysplasia should be considered in the etiology of childhood carpal tunnel syndrome.The surgical outcome of carpal tunnel syndrome is good with early diagnosis and treatment. However, in the case of skeletal dysplasia, the diagnosis of carpal tunnel syndrome may be delayed due to anomalies of the hand and due to the child's difficulty in expressing symptoms. Because of the delay in diagnosis of carpal tunnel syndrome in patients with skeletal dysplasia, the treatment outcomes may not be promising. Electrophysiologic studies should be performed early when the clinical signs are positive.

Management of Persistent Cerebrospinal Fluid Leakage Following Thoraco-lumbar Surgery.

STUDY DESIGN: This was a retrospective study of patients who had developed a dural tear after thoracic and lumbar spine surgery that was not recognized during the surgery, and was treated either by lumbar drainage or over-sewing of the wounds. PURPOSE: To revisit the treatment strategies in postoperative dural leaks and present our experience with over-sewing of the wound and lumbar drainage. OVERVIEW OF LITERATURE: Unintended durotomy is a frequent complication of spinal surgery. Management of subsequent cerebrospinal fluid leakage remains controversial. There is no distinct treatment guideline according to the etiology in the current literature. METHODS: The records of 368 consecutive patients who underwent thoracic and/or lumbar spine surgery from 2006 throug h 2010 were retrospectively reviewed. Seven cerebrospinal fluid fistulas and five pseudomeningoceles were noted in 12 (3.2%) procedures. Cerebrospinal fluid diversion by lumbar drainage in five pseudomeningoceles and over-sewing of wounds in seven cerebrospinal fluid fistulas employed in 12 patients. Clinical grading was evaluated by Wang. RESULTS: Of the 12 patients who had a dural tear, 5 were managed successfully with lumbar drainage, and 7 with oversewing of the wound. The clinical outcomes were excellent in 9 patients, good in 2, and poor in 1. Complications such as neurological deficits, or superficial or deep wound infections did not develop. A recurrence of the fistula or pseudomeningocele after the treatment was not seen in any of our patients. CONCLUSIONS: Pseudomeningoceles respond well to lumbar drainage, whereas over-sewing of the wound is an alternative treatment option in cerebrospinal fluid fistulas without neurological compromise.