Greater tuberosity medial malposition: does it affect shoulder abductor moment?

PURPOSE: The detrimental effect of greater tuberosity malposition on functional scores is well known. Superior or posterior malpositions exceeding five mm lead to excessive loading on the deltoid strength. However, the significance of situations where greater tuberosity becomes medialized due to the compressive effect of the locking plate fixation, especially in fractures with metaphyseal dead space, has not been emphasized. It is hypothesized that this condition may cause shortening of the rotator cuff moment arm and consequently impact functional scores. METHODS: Between 2012 and 2018, 52 patients, aged 65,28 (ranging 40-85) proximal humerus fractures treated with locking plate fixation were included in the study. Cephalodiaphyseal angle, greater tuberosity displacement , patients reported outcome and Constant-Murley scores were evaluated. RESULTS: The mean Constant Murley score was determined to be 78.76 (ranging from 38 to 100). According to the patients reported outcome 39 excellent , five good , two fair, six poor results were observed. Avascular necrosis with screw migration was detected in five cases, while one patient experienced implant insufficiency along with varus deformity. Greater tuberosity was found to be positioned between 6 mm posterior-superior and -13 mm medial. Significant medial malposition was observed in three patients, with -9, -12, and -13 mm of medialization, respectively. Cephalodiaphysial angle was determined as 139.30 degrees (ranging from 120 to 150 degrees) and showed weak correlation with the functional score. Greater tuberosity medialization also showed weak correlation with the Constant-Murley score. The values exhibiting deviation were associated with low patient-reported outcome results and functional scores. In the examination of greater tuberosity displacement values, it was observed that Neer type 3 and 4 fractures differed significantly from Neer type 2 fractures regarding to Kruskal-Wallis test. CONCLUSIONS: Medial impaction of greater tuberosity may be the reason of decreased functional scores, similar to superior or posterior malposition. The medialization of greater tuberosity should be considered as a potential factor leading to the shortening of the rotator cuff's abductor moment.

An overview of the orthopedic patient profile in the first five days following February 6th, 2023 Kahramanmaras earthquake: A single-center experience in the earthquake zone.

OBJECTIVES: This study aims to investigate the patient profile at a medium-volume hospital located in the earthquake zone among patients who received orthopedic treatment within the first five days after the natural disaster that was considered a major earthquake. PATIENTS AND METHODS: Between February 6th, 2023 and February 10th, 2023, a total of 338 patients (156 males, 182 females; mean age: 42.2±9.7 years; range, 0 to 87 years) who received orthopedic treatment in our center were retrospectively analyzed. The patients were divided into four groups according to age as follows: infants (younger than one year of age), children (one to 13 years), adults (14 to 59 years), and elderly (60 years or older). RESULTS: Considering the age distribution, 291 (86%) patients were young adults. A total of 173 orthopedic surgeries were performed, including internal fixation in 63 patients, external fixation in 11 patients, upper/lower extremity fasciotomy in 47 patients, amputation in 39 patients, and soft tissue debridement in 13 patients. CONCLUSION: It is of utmost importance to recognize the principles of emergency fracture fixation and fasciotomy to successfully perform orthopedic surgeries after a natural disaster such as a major earthquake, particularly when the number of earthquake victims is considerably high.

The clinical results of lower trapezius tendon transfer with the peroneus longus allograft augmentation combined with interpositional repair with fascia lata in massive irreparable rotator cuff tears.

OBJECTIVES: To investigate the clinical results of lower trapezius (LT) tendon transfer and interpositional repair that were performed simultaneously in patients with massive irreparable rotator cuff tears. METHODS: Between 2018 and 2020 years, 16 patients with massive irreparable rotator cuff tears that were treated with LT tendon transfer and interpositional repair at the same time were included in this study. The mean follow-up period was 29±3 months (24-39 months) and the mean age of patients was 62±9 years (42-73 years). The acromio-humeral distance, active range of motions, Visual Analog Scale (VAS) scores, University of California-Los Angeles (UCLA) scores and Constant-Murley scores were made preoperatively and at the final follow-up. RESULTS: At the final follow-up, forward flexion was increased from 109˚±24.7 to 144˚±22.21 (p=0.005), abduction from 60˚±16.33 to 135˚±16.33 (p=0.005) and external rotation from 12˚±16.87 to 35˚±14.34 (p=0.005). Total UCLA scores were 5.9±2.13 to 22.7±5.29 (p=0.005), Constant-Murley scores were 24±9.43 to 50.2±14.28 (p=0.008), VAS scores were 6.1±1.1 to 2.4±1.35 (p=0.007), mean acromio-humeral distances were 4.64±0.85 mm (3.42-6.23 mm) to 6.58 mm (5.25-8.21 mm) (p=0.005) preoperatively and at the final follow-up. Except one patient who had a frozen shoulder any significant complication was detected. CONCLUSION: Adding interpositional repair to the LT tendon transfer in patients with posterior superior irreparable rotator cuff tear seems to have satisfactory short to mid-term clinical outcomes without an increase in complications.

Treatment of Gustilo-Anderson type III open fractures with segmental long bone loss secondary to gunshot and war injuries in paediatric patients with bone segment transport by the limb reconstruction system (LRS).

OBJECTIVE: The information on firearm- or explosive-related extremity injuries in children is very limited. Reports of segmental bone loss due to these types of fractures are even rarer and the treatment remains a problem. There has been no report of distraction osteogenesis with limb reconstruction system (LRS) specifically in children. We evaluated the treatment results of Gustilo-Anderson type 3 open fractures with segmental bone loss due to firearm injuries by distraction osteogenesis performed with LRS in skeletally immature patients. METHODS: Nine patients with Gustilo-Anderson (GA) type 3 open fractures with segmental bone loss due to firearm injuries who had not completed their skeletal development were included. Two of the patients had GA type 3a, four had type 3b, and the remaining three had type 3c. Bony and functional assessment was conducted using Association for the Study and Application of the Methods of Illizarov (ASAMI) criteria. RESULTS: Mean follow-up period was 20.1 months (range 5.5-35 months). The mean bone loss was 45.5 mm (range 15-80 mm) before the treatment started. The mean time of external fixation (day) was 180.6. The mean distraction index (distraction period per cm) was 11.3 day/cm. The mean time for bone union index (duration of bony union per cm) was 33.7 days/cm. Bony union was achieved in all patients at the end of the treatment. Bony results as per ASAMI score were excellent in seven fractures and good in three. Functional results were excellent in five patients, good in two, and fair in two. We had no fair or poor results with respect to bony results but had two fair functional results. CONCLUSIONS: LRS provides a good treatment choice for children with fractures with segmental bone loss due to firearm injuries. It also provides easy access to the wound with its monolateral construction.

The effect of equine-derived bone protein extract (Colloss-E) in the treatment of cavitary bone defects: an experimental study.

OBJECTIVE: Bone protein extract (BPE) usually requires a carrier or a scaffold for implantation. We aimed to compare the effect of equine-derived BPE, an osteoinductive agent composed of a high amount of type-I collagen and other bone proteins (Colloss-E), with that of human demineralized bone matrix (DBM) for treating cavitary bone defects not requiring scaffold use. METHODS: Rabbit distal femoral condyle was used as a stable cavitary bone defect model. Bone defects of 6-mm diameter and 10-12-mm depth were created in the femoral condyles. Rabbits were assigned into the equine-derived BPE (BPE), human-derived DBM (DBM), and control (C) groups. Approximately 20 mg of BPE was implanted into the defect in the equine-derived BPE group (n=6), whereas 0.3 cc of DBM was implanted in the DBM group (n=6). Defects were left empty in the C group (n=6). The defect area was histologically examined after 6 weeks. RESULTS: There were no instances of macroscopic defect collapse or failure. Histopathological examination revealed that the BPE group had better scores (statistically significant) than both the other groups in terms of quality of union. The BPE group also had higher scores than the DBM group in terms of graft incorporation and new-bone formation. CONCLUSION: The current study revealed results consistent with those of the previous studies concerning BPEs. Equine-derived BPE was found to be successful for treating cavitary bone defects not requiring scaffold use.

Identification of intervertebral disc regeneration with magnetic resonance imaging after a long-term follow-up in patients treated with percutaneous diode laser nucleoplasty: a retrospective clinical and radiological analysis of 14 patients.

PURPOSE: The aim of this study was to demonstrate regeneration of intervertebral discs undergoing laser therapy with sagittal relaxation time (T2) mapping after a long-term follow-up. MATERIALS AND METHODS: Fourteen patients (9 men, 5 women; age range 20-57 years; mean age 36.5 years) treated with percutaneous 908-nm wave-length diode laser nucleoplasty for lumbar disc prolapsus at our clinic between January 2006 and June 2009 were studied. For the application of laser nucleoplasty in the past, patients who did not have central canal stenosis and/or lateral stenosis, sequestered disc fragment, operation scars and bleeding disorders were selected. The intervertebral disc levels undergoing laser therapy were L3-L4 (n = 2) or L4-L5 (n = 12). Patients were called for follow-up visits after a maximum 6-years (n = 2) or a minimum 3 years (n = 3) with a mean of 4.4 years. The patients' clinical status for leg pain was evaluated according to the visual analog scale (VAS) and subsequently, a lumbar magnetic resonance imaging was performed. Sagittal T2 mapping was performed for the intervertebral discs undergoing laser nucleoplasty. We analyzed the relationship between T2 in the regions of interest (ROIs), which is known to correlate with changes in the composition of intervertebral discs, and the degree of degeneration determined using the Pfirrmann grading system and VAS of patients. RESULTS: On the basis of the evaluation of the results of intervertebral discs in all patients, there was a significant increase in T2 in the anterior NP (ROI 2, +10.3 ms; p < 0.05). A significant increase was noted in T2 in the middle NP (ROI 3, +24.6 ms; p < 0.001). The most significant increase was recorded for the posterior NP (ROI 4, +28.6 ms; p < 0.001). No significant decrease was found in T2 in the anterior and posterior AF (ROI 1, -1.5 ms; p = 0.925; ROI 5, -0.1 ms; p = 0.683). According to the Pfirrmann grading system, disc degeneration grades before laser therapy were recorded as grade III (n = 6) and grade IV (n = 8) whereas disc degeneration grades after laser therapy were found to be grade I (n = 6) and II (n = 8). A significant decrease was noted in Pfirrmann grades of disc degeneration after laser therapy (p < 0.0005). CONCLUSIONS: In this study, there was a prolongation of T2 indicating regeneration in the nucleus pulposus after laser therapy and these results were found to be consistent with VAS measurements after a long-term follow-up. This study, which demonstrates the quantitative efficacy of laser therapy, indicates that MRG can be more effectively used in the future.