Posterior Shoulder Dislocation Associated With the Head (Splitting) and Humeral Neck Fracture: Impact of Understanding Radiologic Signs and Experience With an Extended Deltopectoral Approach.

In this paper, our main objective was to emphasize the competency of extended deltopectoral exposure, enforced with the supraspinatus and subscapularis detachment, to gain access to the entire head. The second important point in this paper was to underline the importance of the knowledge that is necessary for interpreting classic radiologic signs of posterior fracture-dislocation of the shoulder. A 47-year-old woman fell down directly onto her shoulder while she was skiing. She was diagnosed with posterior shoulder dislocation, associated with fracture of the head (head splitting) and humeral neck fracture, with the aid of plain radiographs and computed tomographic results. The patient was treated with open reduction and internal fixation of the fracture, through the extended deltopectoral approach, which was augmented with rotator cuff detachment. At the 1-year follow-up, x-rays showed stable fixation with good evidence of healing. One year after the surgery, the patient had no pain, and she regained most of her functionality in her right shoulder with 140 to 150 degrees of lateral elevation (abduction), 140 to 150 degrees of forward flexion , internal rotation hand at T12 vertebra (slightly restricted). These results showed good functionality, with a painless shoulder at the 1-year follow-up. The "double shadow" and "lightbulb" signs are indicative of posterior shoulder fracture-dislocation, and augmented (with the detachment of supraspinatus and subscapularis tendons) traditional deltopectoral incision is suitable for managing these kinds of difficult fracture dislocations.

Trevor's disease: up-to-date review of the literature with case series.

Trevor's disease, also known as dysplasia epiphysealis hemimelica, is a rare nonhereditary skeletal development disorder that affects epiphyses. This type of dysplastic lesion was first reported by Mouchet and Berlot in 1926 under the name 'tarsomegaly'. The main aim of this study is to raise awareness of Trevor's disease among orthopedic surgeons and underline some important aspects of treatment by a detailed presentation of four different possible manifestations of the disease. Four different treatment methods were used on four different patients (three localized in hindfoot ankle region and one classic Trevor's disease case). Treatment methods, localization of the sides involved, different characteristics of entire lower extremity, asymetry, distal femoral lateral epiphysis involvement, and hip involvement were analyzed thoroughly and the results were compared with those found in the most recent literature. Of our four patients, three were localized (hind foot ankle) cases and one was a classic dysplasia epiphysealis hemimelica with hemimelic distribution of the entire lower extremity. We used arthroscopic resection, observation, excision, and temporary hemiepiphysiodesis treatment methods in each of our cases. Clinical follow-up results were reported to be between good and excellent. In sum, our opinion is that the treatment for this condition should be customized according to lesion localization and lesion size. Majority of cases with ankle involvement show good prognosis following excision. Observation is also an alternative in patients who refuse surgery. If an intra-articular lesion is present, the surgeon should perform an arthroscopy for assessment of lesion surface. If the lesion is adapted to the joint curvature, it should be left alone and hemiepiphysiodesis should be considered for correction. The most risky involvements that are related to deformities and limb-length discrepancies are the hip and the knee. This is usually the result of corrective osteotomy targeted at the supracondylar femoral area in immature skeletons. Hemiepiphysiodesis might be a more feasible option in those cases as it provides the surgeon with the choice to remove the staples when necessary.

A Novel Surgical Approach to Coracoid-based Eosinophilic Granuloma and the Technical Trick.

The coracoid base is a very rare location for tumors. It is difficult to diagnose and approach, but easy to dismiss. In this case, the tumor (eosinophilic granuloma of the scapula) was located at the base of the coracoid, and the posterior cortex was eroded by the tumor. Accessing this lesion through the deltopectoral approach with coracoid osteotomy without penetrating the supposed tumor extending posterior soft tissue will be discussed. This approach gives a wider and safer access to the surgeon than the posterior approach. This report presents a customized solution with the deltopectoral approach, and the chevron-type osteotomy to access the coracoid base and tension band wiring to fix the osteotomy side.

[A new technique for aneurysmal bone cysts of the proximal humerus: cortical collapsing]. / Humerus üst uç yerlesimli anevrizmal kemik kistilerinin tedavisinde yeni bir yöntem: kortikal çöktürme.

OBJECTIVES: We evaluated the results of a new technique developed for aneurysmal bone cysts centrally located in the proximal humeral metaphysis leading to widespread destruction. METHODS: The study included seven patients (5 boys, 2 girls; mean age 12.8 years; range 9 to 15 years) who were treated with cortical collapsing and massive fibular autograft for centrally located aneurysmal bone cysts in the proximal humeral metaphysis leading to widespread destruction. All the patients had type II and active tumors according to the criteria of Capanna et al. and Campanacci et al., respectively. Final evaluations included six patients because one patient was lost to follow-up. The mean follow-up period was 49 months (range 12 to 105 months). RESULTS: No complications were seen in the early postoperative period. Radiographic examination showed partial recurrence in two patients; of whom, one patient underwent curettage and bone grafting in the postoperative second year because of pain and discomfort. No deformity was observed. One patient developed shortening of 0.5 cm. Radiographically, all the patients exhibited metaphyseal remodelling one year after surgery. Function of the shoulder joint was near-normal in all the patients. CONCLUSION: In this technique, cortical collapsing reduces the amount of bone graft used, and massive fibular strut grafting provides structural support to prevent deformities.

A new noninvasive controlled intra-articular ankle distraction technique on a cadaver model.

Effective joint distraction is crucial in arthroscopic ankle surgery. We describe an effective and controlled intra-articular ankle distraction technique that we have studied by means of a fresh-frozen cadaver model. Using a kyphoplasty balloon, which is currently used in spine surgery, we tried to achieve a controlled distraction. After the fixation of the cadaver model, standard anteromedial and anterolateral portals were used for ankle arthroscopy. From the same portals, the kyphoplasty balloon was inserted and placed in an appropriate position intra-articularly. The necessary amount of distraction was achieved by inflating the kyphoplasty balloon with a pressure regulation pump. All anatomic sites of the ankle joint were easily visualized with the arthroscope during surgery by changing the pressure and the intra-articular position of the kyphoplasty balloon. Ankle distraction was clearly seen on the arthroscopic and image intensifier view. The kyphoplasty balloon is simple to place through the standard portals and the advantage is that it allows easy manipulation of the arthroscopic instruments from the same portal.

[An arthroscopic study on the anterior intermeniscal ligament]. / Anterior intermeniskal ligamentin artroskopik degerlendirilmesi.

OBJECTIVES: An arthroscopic study was made on the presence and anatomic features of the anterior intermeniscal ligament with regard to its thickness and attachment patterns to the anterior horn of the menisci, together with its relationship with associated non-traumatic intraarticular disorders of the knee. METHODS: This multicenter study included 136 consecutive patients (80 males, 56 females; mean age 40 years; range 15 to 74 years) in whom the presence of anterior intermeniscal ligament was sought during arthroscopic examination of the knee. Arthroscopic features of the ligament was evaluated by probe. RESULTS: The anterior intermeniscal ligament was detected in 80 knees (58.8%). Its presence did not differ significantly with respect to sex (33 females, 58.9%; 47 males, 58.8%; p>0.05). A cord-like appearance was observed in 19 cases (14%), whereas a membranous-like structure was identified in 61 cases (44.9%), 34 (55.7%) of which could only be detected following synovial abrasion. Attachment patterns according to the Nelson and LaPrade's description showed type A in 47 cases (58.8%), type B in 23 cases (28.8%), and type C in 10 cases (12.5%). Type A was more common among cord-like intermeniscal ligaments, although this did not reach significance (p>0.05). No significant association was found between the presence of the ligament and intraarticular disorders. The detection of discoid lateral meniscus was significantly associated with the presence of a cord-like intermeniscal ligament (p<0.05). Of eight cases with discoid lateral meniscus (5 complete, 3 incomplete), five patients exhibited a cord-like anterior intermeniscal ligament. CONCLUSION: This is the first arthroscopic study to define the anatomy and the incidence of the anterior intermeniscal ligament. Functional features of the ligament should be more clearly demonstrated biomechanically.