Limb salvage and amputation in Type 3C tibial fractures.

OBJECTIVE: The aim of this study was to evaluate the results of limb salvage and primary amputation treatments in patients with Type 3C tibia fractures and compare with normative population data. METHODS: Limb salvage was performed in 20 patients and primary amputation in 14 patients with Type 3C tibia fractures between 1993 and 2009. Mean follow-up period was 5.3 years. Treatment times, complications, number of operations and return-to-work status of groups were compared. The Short Form-36 (SF-36) was used to assess quality of life and domains were compared among the patient groups and normative data. RESULTS: Limb salvage patients had longer treatment periods with more operations and complications than the primary amputation group. Return-to-work percentage was 59% in the limb salvage group and 71% in the amputation group. There was no statistical difference in all SF-36 domains for limb salvage and primary amputation patients. Physical functioning, social functioning, limitation due to emotional problems and pain were statistically lower in all patients than in the general population. CONCLUSION: Type 3C tibia fractures treated with both limb salvage and primary amputation have negative effects on quality of life. Patients should be informed about limited functional capacity, pain complications and problems with return-to-work at the end of treatment. In addition, high rates of limb salvage can be achieved with proper conditions in suitable patients.

[Humeral shaft nonunions: plates and nails]. / Humerus cisim kaynamamalari: Plaklar ve çiviler.

OBJECTIVES: This study aims to compare the functional results of dynamic compression plates (DCP) and interlocked retrograde intramedullary nails (IRIN) used for the treatment of humeral shaft nonunions. PATIENTS AND METHODS: Twenty-six patients (12 males, 14 females; mean age, 42.8 years; range 21 to 61 years) who underwent surgical treatment of humeral shaft nonunion either with DCP (n=13) or IRIN (n=13) between October 1999 and January 2008, were retrospectively analyzed. Treatment consisted of removing previous implants and DCP or IRIN fixation with additional autogenous bone grafts for atrophic nonunions. Union time, range of motion, radiographic length difference, Constant-Murley Scale (CMS), Disabilities of the Arm, Shoulder and Hand (DASH-T) and Mayo Elbow Performance Score (MEPS) were evaluated at a mean follow-up time of 59.5 months (range; 17 to 125 months). RESULTS: There was a statistically significant correlation among the functional scores of DASH-T, MEPS and CMS. No statistically significant difference was observed in the functional outcome between the groups (DCP and IRIN). Range of motion of the elbow joint was significantly impaired in three patients who were plated for distal shaft nonunions. CONCLUSION: Both DCP and IRIN provide satisfactory functional outcomes in the treatment of humeral shaft nonunions. Distal shaft nonunions may demonstrate a decrement in elbow motion associated with distal placement of plates.

Reconstruction of humeral diaphyseal non-unions with vascularized fibular graft.

OBJECTIVE: The aim of this study was to review the results of 5 diaphyseal non-unions reconstructed using vascularized fibular grafts. METHODS: This study included six non-unions (3 males and 3 females; average age: 47 years; range: 21 to 57 years) reconstructed using vascularized fibular grafts between 2002 and 2007. Average duration of non-union was 59 (range: 12 to 156) months. Fixation was achieved with intramedullary nailing in 3 patients and plates in 3. One case was lost to follow-up at the third postoperative month. The remaining five patients were followed up for an average of 37 (range: 12 to 53) months. RESULTS: In four cases, union was achieved with a single operation at an average of 4.4 months. A secondary intervention for grafting was required for one patient for inadequate consolidation of the proximal bone-graft interface. Mean radiographic humeral length difference was 3.6 (range: 1 to 7) cm. Average elbow range of motion was 130 (range: 100 to 145), shoulder flexion 167.5 (range: 165 to 170), shoulder abduction 172.5 (range: 170 to 180), internal rotation 75 (range: 70 to 80), and external rotation 92.5 (range: 80 to 100) degrees. Mean DASH score was 10 (range: 5 to 19). According to the Tang system, 3 patients had excellent and 2 good clinical evaluations. Radiologic evaluation revealed four excellent and one fair result. No donor site morbidity was detected. CONCLUSION: Our results suggest that vascularized fibular grafting is an effective treatment option for the reconstruction of humeral diaphyseal non-unions.

Free vascularized fibular grafts in Type 3 open tibia fractures.

OBJECTIVE: The aim of this study was to evaluate the results and complications of free vascularized fibular grafting (FVFG) for the reconstruction of bone defects in Gustilo Type 3 open tibia fractures. METHODS: Free vascularized fibular grafting was performed on open tibia fractures with a bone defect of an average of 10 (range: 6 to 18) cm in 21 patients (19 males, 2 females; mean age: 32 years; range: 16 to 47 years). Primary FVFG was performed for 15 patients with open fractures and secondary FVFG in 6 patients with osteomyelitis due to open fractures or defective nonunions. Bony unions were evaluated retrospectively. At a mean follow-up time of 74 (range: 18 to 216) months, 18 patients were examined for malalignment, shortness, and range of motion. Quality of life was evaluated using the Short Form 36 (SF-36). RESULTS: Mean bony union times for the proximal and distal fibula were 19 (range: 16 to 24) weeks and 20 (range: 16 to 28) weeks, respectively. Proximal nonunion was detected in three patients. Mean external fixation removal time was 6.3 (range: 3 to 14) months. Stress fractures occurred in 15 patients following fixator removal. Malalignment of over 5 degrees was detected in 7 patients and shortness over 2 cm was detected in 4 patients. SF-36 scores were significantly lower in the domains of physical functioning, role limitation due to physical problems, bodily pain, general perception of health, social function, and role limitation due to emotional problems. Mental health, energy and vitality were similar to the healthy reference group. CONCLUSION: Free vascularized fibular grafting appears to be a reliable and effective method for reconstructing bone defects and soft tissue defects in a single session in open tibia fractures.

[Long-term results of major upper extremity replantations].

OBJECTIVES: The aim of this study was to evaluate long-term clinical and functional results of major upper extremity replantations. METHODS: We retrospectively evaluated 26 male patients (mean age 27 years; range 3 to 69 years) who underwent major upper extremity replantations and had a mean follow-up of 11.3 years (range 5 to 19 years). The levels of the replantations were transmetacarpal (n=6), wrist (n=4), forearm (n=5), elbow (n=4), and arm (n=7). Amputations were of clean-cut, crush, and avulsion types in seven, eight, and 11 patients, respectively. Secondary operations were performed in 19 patients. Functional results were assessed using the Chen's criteria and the Turkish version of the DASH questionnaire (Disabilities of the Arm, Shoulder and Hand) was administered. RESULTS: The mean surgical shortening was 37.2 mm, and the final mean radiographic shortening was 52.2 mm. The mean grip and pinch strengths on the affected side were 12.3 kg and 3.6 kg, compared to the strengths of 37.6 kg and 8.7 kg on the normal side, respectively. Monofilament testing showed sensory recovery in 20 patients. Two-point discrimination could be made by 18 patients for the median nerve, and by 17 patients for the ulnar nerve. According to the Chen's criteria, the results were very good or good in 17 patients (65.4%), moderate in three patients (11.5%), and poor in six patients (23.1%). Functional results were correlated with the level (r=0.71) and type (r=0.65) of injury, with injuries at the elbow level and avulsion injuries being associated with a worse outcome. The mean DASH score was 6.7 (range 0 to 32.5) and the mean scores of Chen's grade I-II and grade III-IV patients differed significantly (p<0.05). CONCLUSION: Lower DASH scores show increased satisfaction of the patients and improved use of their replanted extremities as the helper arm whereby functional deficiency is somewhat compensated.

Elbow arthrolysis in severely stiff elbows.

INTRODUCTION: This study involves the results of open elbow arthrolysis performed on a series of patients having fixed joint contracture. PATIENTS AND METHODS: Eighteen patients were treated with open arthrolysis. Eleven patients had very severely stiff elbows (flexion arc less than 30 degrees ), five patients had severely stiff elbows (31 degrees -60 degrees ) and two patients had moderately stiff elbows (60 degrees -90 degrees ). Fixed flexion deformity was observed in nine patients preoperatively.The mean interval between the trauma and arthrolysis was 14.8 months. The mean age was 27 years. After radiological examination, lateral kocher incision was used on 13 patients, medial and lateral incision on 3 patients, transolecranon approach on 1 patient and anterior and posterior approach on 1 patient. External fixator was applied on four patients. Fasia lata interposition was performed in three patients. Additional procedures were as follows, bone fixation in five patients, bone grafting in two patients, nerve grafting in one patient, subcutaneous ulnar nerve transposition in three patients. The average follow-up time was 47 months. RESULTS: At the final evaluation, the mean extension deficit had improved from 55 degrees to 32 degrees . The mean end flexion increased from 81 degrees to 124 degrees postoperatively. The flexion arc of three patients in whom heterotopic ossification was excised had increased to 65 degrees . Infection was diagnosed in two patients (11%). CONCLUSION: The importance of this study is that the patients have fixed deformities and a long follow-up time. Severely stiff elbow is one of the main indications of open arthrolysis in the patients without muscle atrophy. We suggest sequential arthrolysis as an effective way to obtain good range of motion especially in severe stiff elbows as well as to maintain the ligamantous stability of the elbow joint.