Do Patients With Acute Isolated Pubic Ramus Fractures Have To Be Hospitalized?

A total of 129 patients were included in the study. Haemoglobin levels on admission and at 24 hours were evaluated. Radiographs and computed tomography of the pelvis were also evaluated. The patients were divided into subgroups, according to the accompanying occult posterior pelvic injuries, whether they received anticoagulant-antiaggregant treatment, the number of pubic ramus fractures (single or multiple), the level of energy (low or high) and the zone(s) of the fracture(s). The mean haemoglobin decrease was 1.21 g/dL. Forty-six of the patients were under anticoagulant or antiaggregant treatment. Fifty-one of the fractures occurred due to low energy trauma. Posterior ring injuries were observed in 75 of the patients. Haemoglobin level decreases were statistically significant in injuries with high energy trauma aetiology, in patients using antiaggregant or anticoagulant and in fractures of the lateral half of the superior pubic ramus. It is important to follow all pubic ramus fractures closely because, even in low energy trauma, haemoglobin levels could decrease significantly. We recommend hospitalization to monitor this group of patients.

Which factor is most important for occurrence of cutout complications in patients treated with proximal femoral nail antirotation? Retrospective analysis of 298 patients.

INTRODUCTION: Mechanical complications, such as cut-out of the head-neck fixation device, are the most common causes of morbidity after trochanteric femur fracture treatment. The causes of cut-out complications are well defined in patients who are treated with sliding hip screws and biaxial cephalomedullary nails but there are few reports about the patients who are treated with proximal femoral nail antirotation. AIM: The purpose of this study was to evaluate the most important factor about occurance of cutout complication and also to evaluate the risks of the combination of each possible factors. PATIENTS AND METHODS: Overally 298 patients were enrolled in the study. Medical records were reviewed for patients' age, fracture type, gender, anesthesia type and occurance of cut-out complication. Postoperatively taken radiographs were reviewed for tip-apex distance, obtained collo-diaphyseal angle, the quadrant of the helical blade and Ikuta reduction subgroup. The most important factor (s) and also predicted probability of cut-out complication was calculated for each combination of factors. RESULTS: Cut-out complication was observed in 14 patients (4.7 %). The most important factor about occurrence of the cut-out complication was found as varus reduction (p: 0.01), the second important factor was found as implantation of the helical blade in the improper quadrant (p: 0.02). Tip-apex distance was found as third important factor (p: 0.10). The predicted probability of cut-out complication was calculated as 45.6 % when whole of the four surgeon dependent factors were improperly obtained. CONCLUSION: Althought obtaining proper tip-apex distance is important to prevent cutout complication in these fractures, if the fracture is not reduced in varus position and helical blade is inserted in the proper quadrant, possibility of cut-out complication is very low even in the patients with high tip-apex distance.

Nailing or plating for subtrochanteric femoral fractures: a non-randomized comparative study.

BACKGROUND: The aim of the present study was to compare the outcomes of reverse less invasive stabilization system for distal femur (LISS-DF) plates and proximal femoral nail antirotation (PFNA) in the treatment of patients with subtrochanteric fracture. METHODS: Thirty-one patients with 32 fractures were included in this study. The PFNA group consisted of 16 patients, and the reverse LISS-DF plate group consisted of 15 patients. Intraoperative data such as surgical time (min), amount of blood transfusion (units and erythrocyte suspensions) and radiation time (seconds) were noted. Time elapsed until fracture consolidation (weeks), time until full weight bearing (weeks), mean Harris hip score and length of stay (LOS) at hospital (days) were recorded postoperatively. RESULTS: The reverse LISS-DF group had a significantly longer elapsed time until fracture consolidation (p < 0.05). The mean radiation time was significantly longer (p < 0.05), and the Harris hip scores at last control were significantly higher (p < 0.05) compared with the PFNA group. No significant differences were determined in terms of complications and re-operation rates. CONCLUSION: This study demonstrated that in the reverse LISS-DF-treated group, the mean time for bone union was longer and weight bearing was delayed. Considering the surgical technique, minimal surgical approach, reduced amount of blood transfusion and superior functional results following surgery, we concluded that the PFNA system offers advantages over reverse LISS-DF plating in the treatment of subtrochanteric femur fractures.

Posterior fixation of thoracolumbar burst fractures: is it possible to protect one segment in the lumbar region?

BACKGROUND: The treatment for thoracolumbar burst fractures is controversial. The aim of this retrospective study was to compare intermediate-segment (IS) and long-segment (LS) instrumentation in the treatment for these fractures. METHODS: IS instrumentation was considered as pedicle fixation two levels above and one level below the fractured vertebra (infra-laminar hooks attached to lower vertebra with pedicle screws). LS instrumentation was done two levels above and two levels below the fractured vertebra. Among a total of 25 consecutive patients, Group 1 included ten patients treated by IS pedicle fixation, whereas Group 2 included fifteen patients treated by LS instrumentation. RESULTS: The measurements of local kyphosis (p = 0.955), sagittal index (p = 0.128), anterior vertebral height compression (p = 0.230) and canal diameter expansion (p = 0.839) demonstrated similar improvement at the final follow-up between the two groups. However, there was a significant difference (p < 0.05) between Group 1 and Group 2 regarding clinical outcome [Hannover scoring system, Oswestry disability questionnaire and the range of motion of the lumbar region compared to neutral (0°)]. CONCLUSIONS: The radiographic parameters were the same between the two groups. However, the clinical parameters demonstrated that IS instrumentation is a more effective management of thoracolumbar burst fractures.

Retrospective comparison of external fixation versus volar locking plate in the treatment of unstable intra-articular distal radius fractures.

The aim of this study is to compare the radiological and functional outcomes of open reduction and volar locking plates versus external fixation (EF) in the treatment of unstable intra-articular distal radius fractures. In this retrospective comparative study, 69 of 80 patients who underwent an operation for AO/ASIF C1, C2 and C3 distal radius fractures were assessed. Functional evaluation was performed using the Gartland-Werley scoring system and the PRWE scale, and wrist range of motion and grip strength was also measured. For the radiological assessment, radial inclination, volar tilt, radial length, ulnar variance, and articular step-off were compared. The range of movement was better for all parameters in the volar plate group, but only wrist flexion and pronation range differed significantly between the groups (p = 0.037 and p = 0.014, respectively). With the exception of better subjective functional results in the volar plate group, the differences were not significant. With respect to radiological evaluation, all parameters were better in the volar plate group, but only radial inclination and articular step-off were significantly better (p = 0.018 and p = 0.029, respectively). In the volar plate group, two patients had carpal tunnel syndrome and one patient had regional pain syndrome. In the external fixator group, six patients had superficial pin tract infection, two patients had sensory branch injury, and four patients had regional pain syndrome. Volar locking plate fixation appeared as a dependable method for the treatment of intra-articular distal radius, with lower complication rates. On the other hand, EF remains a suitable surgical alternative for these fractures, with easy application and acceptable results.

Comparison of proximal femoral nail antirotation (PFNA) with AO dynamic condylar screws (DCS) for the treatment for unstable peritrochanteric femoral fractures.

PURPOSE: The aim of this study was to compare the results of intramedullary fixation with those of plate-screw fixation for peritrochanteric femoral fracture patients older than 60 years old. METHODS: This article reports on a retrospective review of patients who had peritrochanteric femoral fractures and were treated with a 95° fixed-angle screw plate (DCS) or an intramedullary nailing system (PFNA). Patients with 79 fractures were enrolled in the study; 47 of them were treated with the PFNA system and 37 with the DCS. Followed for at least 1 year, the treatment groups were compared by taking into consideration all demographic and trauma variables. RESULTS: No significant differences were discovered between the two groups with regard to side of injury, mechanism of trauma, associated comorbidities, AO fracture classification, average follow-up duration, mortality, and fracture reduction quality at the 1-year follow-up. The average surgical time was significantly lower in the PFNA group (57 min.) compared to the DCS group (87 min.). Longer operative time was needed in the DCS group, and thus, greater blood loss occurred compared to the PFNA group. The functional results of the PFNA group were found to be significantly better than those of the DCS group. CONCLUSIONS: Owing to some advantages, such as minimal exposure, reduced operative blood loss, and the achievement of biological fixation, PFNA is a better choice for the treatment for unstable peritrochanteric fractures.

Evaluation of the quadrants of femoral neck-head in the cephalomedullary fixation of intertrochanteric fractures with a helical blade: Is inferior posterior quadrant also safe? A clinical study.

OBJECTIVES: This study aims to investigate the positioning of the helical blade to prevent mechanical complications in surgically fixed intertrochanteric fractures (ITFs). PATIENTS AND METHODS: In this retrospective study, 392 patients (158 males, 234 females; mean age: 75.5±13.4; range, 20 to 101) years) with ITFs treated in lateral decubitus position with proximal femoral nail anti-rotation in a single center between January 2009 and January 2017 were evaluated. The fractures were classified according to the Orthopedic Trauma Association classification preoperatively and grouped as stable or unstable. Postoperatively, tip-apex distance (TAD), Baumgaertner reduction criteria, and obtained quadrants were evaluated. Patients with an unstable fracture, proper TAD, and acceptable or good reduction were included in the final evaluation for statistical analysis to investigate the safest quadrant to prevent cut-out complication. RESULTS: Cut-out complications were observed in 19 (4.8%) patients. The scenario; unstable fracture, TAD <25 mm, acceptable or good reduction consisted of 111 patients in total and cut-out complication occurred in four of them (3.6%) (one in center-posterior, one in center-center, one in superior-anterior, and one in superior-center quadrants). There was no statistically significant difference between center-center, inferior-center, and inferior-posterior quadrants (p=0.49). CONCLUSION: Inferior-posterior placement is as safe as central-central or inferior-central placement for blade fixation in the surgical treatment of ITF.

Can major amputation rates be decreased in diabetic foot ulcers with hyperbaric oxygen therapy?

Although hyperbaric oxygen therapy has been used for diabetic foot ulcer since the 1980s, there is little information on its efficacy. The aim of this study is to evaluate whether hyperbaric oxygen can decrease major amputation rates and to determine the predictive factors. A total of 184 consecutive patients were treated with hyperbaric oxygen therapy as an adjunct to standard treatment modalities for their diabetic foot ulcer. Of these patients, 115 were completely healed, 31 showed no improvement and 38 underwent amputation. Of the amputations, nine (4.9%) were major amputations (below knee) and 29 were minor. Major amputations were associated with the Wagner grade (p < 0.0001), with the age of the patients (p = 0.028) and with the age of the wounds (p = 0.018). Hyperbaric oxygen therapy can help to reduce the major amputation rates in diabetic foot ulcer. However, further large, multicentre, randomised controlled studies are needed to make more accurate conclusions.

Leg length discrepancies in adult femoral shaft fractures treated with intramedullary nailing.

BACKGROUND: To evaluate the leg length discrepancy (LLD) retrospectively in adult femoral shaft fractures treated with intramedullary nailing (IMN). METHODS: Sixty-three patients (58 male, 5 female; mean age 29.9+/-12.4; range 15 to 77 years) were included in the study. Fractures were identified according to the Winquist-Hansen (W) system and AO classification. 16 W0, 18 WI, 16 WII, 7 WIII, and 6 WIV fractures and 35 type A, 22 type B, and 6 type C fractures were repaired. Thirty-one (49.2%) patients had multiple injuries. Fourteen patients sustained an open fracture. LLDs were measured on physical examination and using orthoroentgenography. RESULTS: The mean follow-up was 90.2+/-29.9 (39-193) months. The mean LLD was 12.3+/-15.2 [12-(-60)] mm using orthoroentgenography and 12.9+/-13.7 [10-(-60)] mm according to manual measurement. In seven cases, no LLD was observed. Twenty-seven shortenings and one lengthening were observed in the 28 femurs with a discrepancy greater than 10 mm (44.4%). There was no statistical correlation between LLD and open or closed fracture (r=0.02, p=0.86), polytrauma (r=-0.09, p=0.47), or delayed surgery (p=0.31), but there was a tendency to a greater discrepancy in comminuted fractures (WIII, IV) (r=0.33, p=0.007). CONCLUSION: LLD may be seen in high rates in adult femoral shaft fracture cases treated with IMN. Static IMN following absolute restoration of the length may prevent this problem in femoral diaphysis fractures, especially comminuted WIII and IV types.

Treatment of type I capitellar fractures in adolescents.

BACKGROUND: Because fractures of the capitellum are rare in childhood and the young adolescent period, their treatment is still debatable and there appears to be no established treatment protocol. In the present study, we evaluated the results obtained in adolescents with type 1 capitellar fractures who were treated with open reduction and internal fixation with a 3.5 mm lag screw, directed from posterior to anterior. METHODS: Twelve type I capitellar fractures in adolescents were treated with open reduction and internal fixation with a single 3.5 mm cortical lag screw directed from the posterior to the anterior and the results were evaluated by an objective evaluation score (Broberg and Morrey's functional rating index). Mean age of the patients was 13.5. RESULTS: At final examination (24 to 90 months follow-up), mean Broberg and Morrey's functional rating index was 96.7 points (91 to 100 points). All fractures had healed in anatomic position and no avascular necrosis or heterotrophic ossification was observed. CONCLUSION: Since it is essential to obtain the full range of motion at the elbow, accurate open reduction and stable internal fixation are best to manage displaced type I capitellar fracture in children and adolescents. Single cortical lag screw directed from posterior to the anterior without penetrating the joint surface is suitable for this purpose.

Congenital clubfoot associated with an accessory soleus muscle.

A 16-month-old male with previously untreated bilateral clubfeet was admitted to S.B. Izmir Tepecik Education and Research Hospital, Izmir, Turkey. Both feet underwent surgical treatment. During surgery, an accessory soleus muscle was detected on the right side. The accessory soleus muscle had a distinct distal insertion at the superior anteromedial border of the calcaneus and also anterior and medial to the Achilles tendon. He was treated by bilateral complete subtalar release with Cincinnati incision, and the accessory soleus was also cut and the distal part resected. At the final follow-up visit, when the patient was 6 years and 9 months old, both feet had a normal appearance and appeared normal on radiograph and magnetic resonance imaging, with no presence of the accessory soleus muscle or its remnant. In our opinion, awareness of the association between an accessory soleus muscle and clubfoot, and sectioning of this muscle during surgery may improve surgical results.

Solitary bone metastasis in the tibia as a presenting sign of endometrial adenocarcinoma: a case report and the review of the literature.

BACKGROUND: Metastasis to bone from endometrial adenocarcinoma is rare, when metastasises it usually locates in axial skeleton. Metastasis to extremities is extremely rare. Additionally the detection of the bone metastasis as a presenting feature is uncommon. In the present study we report the 10th cases of bone metastasis in the literature which located at tibial diaphysis and originated from endometrial adenocarcinoma as a presenting feature of the primary disease. CASE: Single tibial lesion was observed in a 70 years old woman. Biopsy confirmed metastatic adenocarcinoma of the unknown origin. We couldn't find the primary origin with aggressive work-up. Tibial lesion regressed with radiotherapy. Endometrial adenocarcinoma is detected after the end of disease-free one year with the symptom of vaginal bleeding. After 47 months from initial tibial lesion and 35 months from gynaecologic operation, patient is still alive and disease free. DISCUSSION: Patients with endometrial adenocarcinoma presenting an isolated skeletal metastasis may exhibit an unusual group with a better prognosis.

Post-transplant femoral head avascular necrosis: a selective investigation with MRI.

BACKGROUND: We investigated the presence of femoral head avascular osteonecrosis (FHAVN) by a selective investigation with MRI at follow-up. MATERIAL/METHODS: A total of 331(200 men, 131 women) renal transplants were included. They were transplanted at the mean age of 31.4 (9-63) years. The mean follow-up time of all patients after transplantation was 60.6 (6-233) months, and the mean current age 36.6 (11-66) years. All transplants filled out a questionnaire on musculoskeletal symptoms and underwent a detailed clinical examination. Magnetic resonance imaging was done in cases of hip joint pain in groin, buttock, thigh and knee and in 50 asymptomatic transplants. FHAVN were identified according to Ficat Arlet classification. RESULTS: 43(13%) patients reported pain without previous trauma. In the clinical examination, limited ranges of motion of the hip were noted in 13 of them. FHAVN was detected in 11 of 43 patients. Disease was bilateral in two of the eleven patients. Of the 662 femoral heads, 43 were associated with hip pain whereas the remaining 619 were asymptomatic. Avascular osteonecrosis was not confirmed in the asymptomatic 100 hips with magnetic resonance imaging. CONCLUSIONS: A selective investigation of FHAVN may be used to diagnose in renal allograft recipients with painful hips at follow-up. With a retrospective selective analysis, the presence of FHAVN was low among renal transplantation recipients at the end of the study.

Effects of three- or four-cortex syndesmotic fixation in ankle fractures.

BACKGROUND: There is no study comparing how Weber type C ankle fractures treated with either three- or four-cortex syndesmotic fixation affects the structure of the syndesmosis. METHODS: In a retrospective study, 46 patients were separated into two groups: 22 patients with three-cortex fixation and 24 patients with four-cortex fixation. All of the patients were evaluated clinically and radiographically at least 1 year after removal of the syndesmosis screws. RESULTS: There were three types of joint space obliteration: type 1, synostosis on plain radiographs; type 2, an incomplete bony bridge on magnetic resonance imaging with normal plain radiographs; and type 3, fibrous obliteration of the joint space. Although obliteration of the joint space was significant (P < .005) after four-cortex fixation, radiologic results did not affect the clinical outcome. CONCLUSION: Four-cortex fixation for diastasis after an ankle fracture should not be a routine procedure. We advocate three-cortex fixation because the clinical results are no different and there is less syndesmotic space obliteration postoperatively.

Comparison of Second and Third-Generation Nails in the Treatment of Intertrochanteric Fracture: Screws versus Helical Blades.

OBJECTIVE: The aim of this study was to compare the radiological and functional outcomes of anti-rotation trochanteric nails (ATNs) with proximal femoral nail anti-rotation (PFNA) in the treatment of intertrochanteric femur fractures in elderly patients. MATERIALS AND METHODS: In total, 165 intertrochanteric fractures were treated between January 2007 and January 2010. One hundred forty patients were included. The operation time, amount of blood loss, fluoroscopy screening time, and length of hospitalization were recorded. The radiological position of the implant, quality of fracture reduction, and tip-apex distance were evaluated, and the postoperative complications as well as functional condition of the patients were assessed. RESULTS: There were no significant differences between the ATN and PFNA groups for the presence of general complications, length of hospitalization, and functional capacity. The mean operation time, blood loss amount, and fluoroscopy screening time were more in the ATN group than in the PFNA group. Reoperation was needed for nine and two patients in the ATN and PFNA groups, respectively, because of implant-related complications. CONCLUSION: Both ATNs and PFNA were suitable for the fixation of intertrochanteric fractures, but the risk of complication occurrence and need for reoperation were found to be higher in patients who were treated with ATNs.

Is surgeons' experience important on intra- and inter-observer reliability of classifications used for adult femoral neck fracture?

PURPOSE: To evaluate whether surgeons' experience affect inter- and intra-observer reliability among mostly used classification systems for femoral neck fractures. MATERIAL AND METHODS: A power point presentation was prepared with 107 slides which were antero-posterior radiographs of each femoral neck fracture. Five residents, 5 orthopaedic surgeons and 5 senior orthopaedic surgeons reviewed this presentation and classified the fractures according to Garden, Pauwels and AO classifications. The order of the slides was changed and reviews were repeated after 3 months. Fleiss kappa and intraclass correlation coefficient values were calculated to evaluate inter and intra-observer reliability. RESULTS: Garden and AO classifications' inter-observer reliabilities were similar and higher than Pauwels classification. Among three experience groups, the inter-observer reliability for Garden classification was highest in senior surgeon group, the interobserver reliability for AO classification was highest in surgeon group, and interobserver reliability of Pauwels classification was highest in low experienced groups (residents and surgeons). Intra-observer reliability was highest for Garden and lowest for Pauwels classifications. Surgical experience was found to be not effective for intraobserver reliability. CONCLUSION: Both Garden and AO classifications were more reliable than Pauwels classification. Surgical experience was not significantly important on these three classification systems' evaluation. LEVEL OF EVIDENCE: Level IV, Diagnostic study.

[Treatment of two-part proximal humeral fractures with external fixators]. / Proksismal humerusun iki parçali kiriklarinin eksternal fiksatörle tedavisi.

BACKGROUND: We aimed to evaluate the results of the closed manipulation or transcutaneous reduction and external fixation in the treatment of two-part fractures. METHODS: Eight patients with two-part proximal humerus fractures who had been treated in our clinic with closed manipulation or transcutaneous reduction and external fixation between 1996-2001 were evaluated for this study. We evaluated the final functional status according to the Neer's classification system. RESULTS: Mean age of the patients was 42 (21-75) years. The major aetiologic factor was motor vehicle accident (in 5 cases). Follow-up time was 2 to 4.5 years. Mean union time was 16 weeks (10 to 24). Nonunion and avascular necrosis of the humeral head have not been observed in none of the cases. Superficial pin tract infection was developed in three cases. All of them were treated successfully with antibiotics. Functional results according to Neer's classification were as follows: 5 good. 2 fair and 1 failed. Mean score 77, 25 (50 to 89). CONCLUSION: External fixation of displaced two-part fractures of proximal humerus can be assessed as a reliable method with respect to satisfactory fracture reduction and stability, low rate of complications and good early functional results-obtained with this technique.

[Closed reduction and percutaneous pinning with three Kirschner wires in children with type III displaced supracondylar fractures of the humerus]. / Cocuklarda deplase suprakondiler humerus kiriklarinda kapali redüksiyon ve üç adet Kirschner teli ile perkütan çivileme.

OBJECTIVES: We evaluated the results of closed reduction and percutaneous pinning in the treatment of displaced supracondylar fractures of the humerus in children. METHODS: Sixty-one children (41 boys, 20 girls; mean age 7.6 years; range 2 to 13 years) were treated for type III displaced supracondylar fractures of the humerus within the first six hours after trauma. Initial neurologic examinations were normal. Treatment included closed reduction followed by percutaneous pinning with two lateral and one medial K-wires, the last being placed during decreased (80 to 90 degrees) elbow flexion. The ulnar nerve was examined intraoperatively, at the time of discharge, at the end of two weeks, and in the third and six months. On final examinations, the range of motion and carrying angles of both elbows were measured with a goniometer and anteroposterior and lateral radiograms of the affected elbows were examined. The results were evaluated using the clinical scoring system developed by Flynn et al. The mean hospital stay was 3.4 days (range 1 to 10 days) and the mean follow-up was 28.9 months (range 17 to 53 months). RESULTS: Iatrogenic ulnar nerve injury occurred in two patients (3.3%), which showed complete clinical improvement in three months. Union was achieved in all the patients. Superficial pin tract infections were seen in four patients (6.6%); and cubitus varus (1.6%) and myositis ossificans in two patients, respectively. Deep infection or compartment syndrome were not encountered. The results were excellent in 49 (80.3%), good in seven (11.5%), fair in two (3.3%), and poor in three patients (5%). CONCLUSION: Closed reduction and percutaneous pinning with three K-wires is an efficacious and safe procedure with a low complication rate in the treatment of type III displaced supracondylar fractures of the humerus.

[The importance of predicted risk factors in developmental hip dysplasia: an ultrasonographic screening program]. / Gelisimsel kalça displazisi tanisinda bilinen risk faktörlerinin önemi: Seçici ultrasonografik tarama.

OBJECTIVES: To evaluate the role of the risk factors in the diagnosis of developmental hip dysplasia (DDH) by ultrasonographic screening. METHODS: The hips of 327 newborns (151 females, 176 males) with identifiable risk factors including family history (n=20), congenital muscular torticollis (n=19), oligohydramniosis (n=2), breech presentation (n=51), multiple gestation (n=6), pes calcaneovalgus (n=74), clubfoot (n=152), and postural metatarsus adductus (n=3) were examined clinically on the first day of life and by ultrasonography within two weeks after birth. The hips were evaluated according to the Graf method. RESULTS: Clinical examination of 239 newborns were normal. Of these, sonographic abnormalities were found in 15 newborns (6.3%). On the other hand, out of 88 newborns who were found clinically abnormal, ultrasonography findings were normal in 24 cases (27%). According to the Graf method, of 654 hips, 550 were type 1, 81 were type 2a, 15 were type 2c, five were type D, two were type 3a, and one was type 4. Treatment was required for only 19 infants (5.8%), four of whom had been found normal on clinical examination. CONCLUSION: Our data suggest that risk factors are important for early diagnosis of DDH, and that, due to detection of abnormal ultrasonography findings among newborns who had been found normal on clinical examination, screening of all newborns with ultrasonography seems to be essential regardless of the presence of any risk factors.