Comparison of 2 different fixation techniques of comminuted acetabular quadrilateral surface fractures using square bracket-shaped tubular plate or interfragmentary screws in addition to supra/infrapectineal plate fixation: An observational study.

The management of comminuted quadrilateral fractures remains challenging, and treatment options are constantly evolving. The purpose of the present study was to examine the outcomes of 2 different fixation techniques in the management of comminuted quadrilateral fractures. Twenty-two patients with comminuted quadrilateral acetabular fractures were surgically treated with interfragmentary lag screw (group 1) and square bracket-shaped tubular (SBST) plate technique (group 2), in addition to suprapectineal and infrapectineal pelvic reconstruction plate fixation between January 2016 and July 2019 at our clinic. 2 years follow-up control data of each group were compared in terms of radiological and functional results, and complications. According to the functional score comparison, the mean Merle d'Aubigne Postel scoring system (MAP) score was 15.2/15.6 (P = .632), and the mean Harris hip scoring (HHS) system score was 74.65/77.3 (P = .664) in groups 1 and 2, respectively. Radiological comparison was performed according to matta radiological criteria (MRC), and 2 excellent, 6 good, 2 poor, 4 excellent, 4 good, and 4 poor radiological results were observed in groups 1 and 2, respectively. intraarticular screw penetration was detected in 3 patients in group 1, while there was no articular implant penetration in group 2 (P = .001). We believe that satisfactory results can be obtained with the SBST plate technique, offering functional and clinical outcomes that are similar to those of the interfragmentary screw technique. The SBST plate technique is superior in terms of avoiding intraarticular screw penetration and related revision surgery.

The effect of arthroscopic coracoplasty on subscapularis strength in cases of subcoracoid impingement in the absence of subscapularis tear.

Subcoracoid impingement leads to anterior shoulder pain, and arthroscopic subcoracoid decompression (coracoplasty) is the preferred treatment in recalcitrant cases. The purpose of the present study was to evaluate the effect of coracoplasty on the severity of anterior shoulder pain and the strength of the subscapularis muscle and to correlate it with the preoperative and postoperative coracohumeral distance (CHD) (t:transverse, s:sagittal). Sixteen patients without any subscapularis tendon tears who underwent arthroscopic subcoracoid decompression and rotator cuff repair with 2 years follow-up were included. Preoperative and postoperative 2-year assessments of function and pain were performed using the modified Kennedy-Hawkins test, power grading of various subscapularis muscle tests, and ASES scores. Preoperative and postoperative coracohumeral distance (tCHD, sCHD) and coracoid overlap (CO) were measured using MRIs before and after surgery. The Mean Hawkins pain score and coracoid overlap were decreased. The strength scores for subscapularis strength testing, ASES score, maximum degree of internal rotation, and coracohumeral distance increased (P < .05). Changes in belly press strength were negatively correlated with postoperative tCHD (r = -0.6, P = .04) and postoperative sCHD (r = -0.7, P = .008). A significant increase in the internal rotation range of the shoulder, subscapularis strength, and relief of anterior shoulder pain was observed. However, this increase was inversely proportional to the postoperative CHD, indicating the mechanical effect of the coracoid on subscapularis strength.

Postoperative alpha angle seems to be important for the achievement of clinical significance at a minimum 5-year follow-up after primary hip arthroscopy.

The purpose of the present study was to clarify whether there is an association of postoperative alpha value with functional scores or progression of osteoarthritis at X-rays at the midterm after arthroscopic treatment of femoroacetabular impingement (FAI) syndrome with femoral osteoplasty, labral repair or debridement and rim trimming. A retrospective review of prospectively gathered data from 2013 to 2017 was performed. All patients who underwent first-time unilateral hip arthroscopy for FAI resection with 5-year follow-up were included. Patient-reported outcomes included the modified Harris Hip Score (mHHS) and Visual Analog Scale for Pain (Pain VAS). The progression of osteoarthritis (Tönnis grade) and radiological parameters (alpha angle, lateral center-edge angle [LCEA] and head-neck offset) were evaluated. A receiver operating characteristic (ROC) analysis was used to evaluate the correlation between significant variables and achievement of patient-acceptable symptomatic state (PASS) and degree of osteoarthritis. We identified 52 patients with a minimum 5-year follow-up (average, 6.7 years). The average patient age was 33.9 ± 11.5 years. There were 19 (36.5%) female patients. The mHHS improved from 60.1 ± 13.4 before surgery to 86.8 ± 14 after surgery (P < 0.001). The Pain VAS decreased from 6.21 before surgery to 2 after surgery (P < 0.001). Overall, 69% achieved the PASS for mHHS. The ROC curve for postoperative alpha angle demonstrated acceptable discrimination between patients achieving a fifth-year PASS value and those who did not have an area under the curve of 0.72. Patients having a postoperative alpha angle of ≤48.3° achieved the fifth-year PASS value at a significantly higher rate than patients having a postoperative alpha angle of >48.3° (P = 0.002). The postoperative alpha angle is a predictor of the achievement of the fifth-year PASS value for the mHHS. A threshold of ≤48.3° had a sensitivity of 0.75 and a specificity of 0.69 to predict positivity. Level of evidence IV.

A device that facilitates screwing at an appropriate angle in quadrilateral surface fractures: 105-degree drill attachment.

BACKGROUND: Within this study, we aimed to investigate the radiological and functional outcomes of acetabular fractures involving quadrilateral surface using 105° drill attachment in the anterior intrapelvic approach. METHODS: The 35 patients who underwent surgical treatment from January 2016 and January 2020 for acetabular fractures involving quadrilateral surface with anterior intrapelvic approach using 105° drill attachment and a minimum of 12 months of postoperative follow-up were included. Perioperative complications, operation duration, and the quality of reduction were evaluated. Reduction quality was classified as poor, imperfect, and anatomic. Functional evaluation was performed according to the Harris Hip Score (HHS) and Merle d'Aubigne Score. RESULTS: Among 35 patients (median age 36 (21-80)), radiological results of the acetabular fixations were anatomic, imperfect, and poor in 28 (80%), 5 (14.3%), and 2 (5.7%) patients, respectively. Postoperative 1-year functional outcomes with Merle d'Aubigne scores and HHS were median 18 (10-18) and 90 (60-96), respectively. The clinical outcomes of the patients showed concordance with reduction quality. The median operation duration was 180 minutes (range 125-270). Iatrogenic neurovascular damage was not noted in any patients. DISCUSSION: Reduction and fixation of deep intrapelvic fractures are risky and difficult due to the narrow anatomy and adjacent crucial neurovascular structures. As the 105-degree drill application is safe and easy to intervene in, short surgery duration and satisfactory results with minimum complications can be obtained with a 105 angulated drill in the deep pelvic region.

Comparison of the Radiological and Functional Results of Tight Rope and Clavicular Hook Plate Technique in the Treatment of Acute Acromioclavicular Joint Dislocation.

Purpose/Aim: Options for surgery for acromioclavicular (AC) joint dislocation vary considerably. This study aimed to examine the functional and radiological results of patients who were operated on using the tightrope (TR) or clavicular hook plate (CHP) technique in the treatment for AC joint dislocation. Materials and methods: The data gathered from 35 consecutive patients who were operated on for AC joint dislocation were analyzed retrospectively in terms of their radiological and functional outcomes. Results: Thirty-two (91.4%) of the 35 patients were male and 3 (8.6%) were female. Thirty (85.7%) patients were classified as Rockwood type 3 and 5 (14.3%) as type 5. Twenty-one patients operated on using the TR technique were categorized as group 1, and 14 patients treated with the CHP technique formed group 2. Functional results were evaluated using the Constant-Murley shoulder scoring system; no statistically significant difference was observed between type 3 and 5 AC separation (p = 0.337). The mean Constant scores of type 3 and 5 injuries were 82.96 and 88.6, respectively. A significant relationship was noted between reduction quality and functional scores (p = 0.006). Postoperative osteoarthritis was seen in 12 (57.14%) patients in group 1 and 7 (50.00%) patients in group 2. In terms of surgery duration, 50.57 minutes in group 1 and 35.71 minutes in group 2 were noted. A statistically significant difference was found between the two groups in terms of surgery duration (p < 0.05). Conclusions: TR and CHP techniques, which do not differ significantly in terms of their clinical results, can be used safely in the treatment of AC separation.

Evaluation of femoral head bone quality by Hounsfield units: a comparison with dual-energy X-ray absorptiometry.

BACKGROUND: Osteoporosis is associated with decreases in bone mineral density (BMD) and is diagnosed using dual-energy X-ray absorptiometry (DXA). Computed tomography (CT), performed in routine practice, can also be used to evaluate bone quality without additional cost. PURPOSE: To determine whether Hounsfield units (HU), a standardized CT attenuation coefficient, measured from the femoral head correlated with DXA-measured BMD. MATERIAL AND METHODS: We evaluated 82 patients (14 men, 68 women; mean age, 67 years) undergoing femoral DXA and CT (non-enhanced abdominopelvic and hip scans) with 130 kV to determine whether HU correlated with T-scores. HU were measured by two radiologists using the largest spherical region of interest including the medullary bone of the femoral head from the junction point of the most caudal section of the femoral head with the femoral neck in 5-mm axial sections. The correlations of both sides' HU values with their ages and DXA femur T-score were evaluated. RESULTS: HU values obtained from both femoral heads showed significant variation between the osteoporotic and non-osteoporotic groups (both P = 0.000) and strongly correlated with each other and DXA femur T-scores (left r = 0.75, right r = 0.73, respectively). In ROC curve analysis, predictive power of left HU values in identifying patients with osteoporotic femur DXA T-score was 0.905, and for right HU values it was 0.924. Osteoporosis cutoff values were 198 HU and 204 HU for the left and right hips, respectively. CONCLUSIONS: HU obtained from CT performed in routine practice correlated with the DXA scores, thus providing an alternative method to determine regional bone quality without additional cost. This may be useful when choosing a fixation method, especially in trauma cases with already-performed abdominopelvic or pelvic CT in emergency services.

Perioperative outcomes following a hip fracture surgery in elderly patients with heart failure with preserved ejection fraction and heart failure with a mid-range ejection fraction.

BACKGROUND: To examine the influence of heart failure (HF) with preserved ejection fraction (HFPEF) and HF with mid-range ejection fraction (HFmrEF) on perioperative cardiac and noncardiac outcomes following hip fracture surgery. METHODS: Data of elderly patients (≥ 65 years) who underwent hip fracture surgery were retrospectively analyzed in this study. Patients with a left ventricular ejection fraction (LVEF) <40% were not included in this study. The definition of preoperative HFPEF (LVEF ≥50%) and HFmrEF (LVEF 40%-49%) was based on clinical documentation of HF in patients' medical records before surgery. The primary outcomes of this study were perioperative adverse events and mortality. The secondary outcome of interest was the length of stay in the hospital. RESULTS: A total of 328 patients (mean age 79.2±8.7 years, and 57.3% female) were enrolled. Of the study population, 250 (76.2%) patients had no HF, 50 (15.2%) patients had HFPEF, and 28 (8.6%) patients had HFmrEF before surgery. The frequency of perioperative cardiovascular and non-cardiovascular complications was similar to a rate of 7.0%. The mean length of hospital stay was 8.1±5.8 days, and the in-hospital mortality rate was 4.6%. Patients with HFPEF and HFmrEF had a longer length of stay and were more likely to experience perioperative complications and death than the patients without HF. Multivariate analyses showed that the presence of HFPEF and HFmrEF were both associated with increased rates of perioperative complications and mortality. CONCLUSION: Our findings suggest that the presence of HFPEF and HFmrEF may predict perioperative adverse events and mortality in elderly patients undergoing hip fracture surgery.

Effects of different anesthesia techniques on intraoperative blood loss in acetabular fractures undergoing the Modified Stoppa approach.

BACKGROUND: This study aims to evaluate the effects of the anesthesia technique on the intraoperative blood loss in acetabular fracture patients undergoing the Modified Stoppa approach. METHODS: We retrospectively identified 63 patients who underwent a Modified Stoppa approach for acetabular fracture from January 2014 to July 2018. A total of 20 patients were excluded from this study for the following reasons: bilateral acetabular fractures (n=6), undergoing antiaggregant treatment (n=3), incomplete anesthesia records (n=3), emergency pelvic surgery due to hemodynamic instability (n=5), splenic rupture (n=2), and liver laceration (n=1). The patients were divided into two groups as follows: patients undergoing general anesthesia (GA) (n=22) and patients undergoing combined epidural-general anesthesia (CEGA) (n=21). The main outcome measurements studied were the intraoperative blood loss and the need for intraoperative and/or postoperative blood transfusions. RESULTS: No statistically significant differences were found between the groups concerning the age, gender, type of fracture, mechanism of injury, time from injury to surgery, Injury Severity Score, associated injuries, and comorbidities (p>0.05). The mean intraoperative blood losses were 717.27 ml (300-1.600 ml) in the GA group and 473.81 ml (150-1.020 ml) in the CEGA group (p<0.001). In the cases with only an isolated acetabular fracture, the intraoperative blood transfusion means were 2.43 units (1-5 units) in 14 patients in the GA group and 1.27 units (1-4 units) in 15 patients in the CEGA group (p<0.001). CONCLUSION: Less intraoperative bleeding was seen in those patients undergoing CEGA when compared to those undergoing GA. This is a significant advantage for acetabular surgery, which has a long learning curve and a high risk of bleeding.

Labral tears with axial plane disorders.

OBJECTIVES: This study aims to determine if there is an axial plane coverage insufficiency in patients with symptomatic labral tears compared to the contralateral asymptomatic side and healthy control subjects. PATIENTS AND METHODS: This retrospective study was conducted between December 2017 and January 2019. Thirty patients (21 males, 9 females; mean age 28 years; range, 20 to 36 years) operated due to unilateral symptomatic acetabular labral tears secondary to femoroacetabular impingement were evaluated. Twenty asymptomatic patients (13 males, 7 females; mean age 27±9 years; range, 19 to 36 years) were included in the control group. The relationship between acetabular morphology and labral tear was investigated with the comparison of unilateral symptomatic hips with contralateral asymptomatic hips and the control group by using radiological parameters on plain radiographs and computed tomography. RESULTS: When the patient group symptomatic side was compared to the control group, acetabular anteversion angle (A A A) and alpha (α) angle were higher, while posterior acetabular sector angle and horizontal acetabular sector angle were lower. When the asymptomatic side was compared to the control group, AAA was higher in the patient group. There was no difference between the symptomatic and asymptomatic sides in the patient group; the symptomatic side yielded a higher α; angle. CONCLUSION: Posterior axial plane coverage deficiency in combination with cam deformity (increased α angle) seems to play a role in the pathogenesis of symptomatic acetabular labral tears, even creating a side-to-side difference in some individuals.

Primary Cutaneous Aspergillosis in Immunocompetent Adults: Three Cases and a Review of the Literature.

Primary cutaneous aspergillosis (PCA) can rarely affect immunocompetent people. There is limited knowledge about the prevalence, diagnosis and management of the disease because there are only case reports or small case series in the literature. For this reason, the diagnosis and treatment of three immunocompetent adult patients diagnosed with PCA were discussed by reviewing the literature. In the current report, in addition to treatment with voriconazole for 8-12 weeks we performed repeated surgical debridement for the treatment of these cases. After two negative tissue cultures, the wounds were either successfully closed primarily or reconstructed using a skin graft. Management of PCA cases will become easier as more reports and further studies of PCA contribute to our shared knowledge. Currently, the most appropriate management approach is to make individualized treatment decisions according to the patients' clinical features and treatment response which includes several surgical debridement as well as antifungal therapy.

Crescent Technique with Dual C-Shaped Reconstruction Plates for Posterior Acetabular Wall Fractures.

Background: Here we have defined a novel technique for repairing posterior acetabular wall fractures called the "crescent technique," in which dual C-shaped reconstruction plates overlap at the distal ends and, if necessary, at the proximal ends. We also analyzed the efficacy and reliability of this method. Patients and Methods: This was a retrospective analysis of 27 patients undergoing the crescent technique. All of the fractures were treated by the senior author for a mean of 7.9 days (0-15 days) after the trauma. The mean follow-up period was 19 months (13-29 months). The clinical results were evaluated using the modified clinical grading system developed by Merle d'Aubigne and Postel, and then modified by Matta. The radiographs were graded according to the criteria described by Matta. Results: In the clinical grading, 16 (59%) of the patients were excellent and very good, 5 (19%) were good, 3 (11%) were moderate, and 3 (11%) were poor. According to the Matta radiological evaluation criteria, 19 (70%) were excellent, 4 (15%) were good, 4 (15%) were fair, and none were poor. Statistically significant consistency was seen between the clinical and radiological results (p = 0.002). Conclusions: The crescent technique is a dual plate technique modification that can provide a stable fixation. It appears to be an effective and reliable method for treating posterior wall fractures of the acetabulum.

Preoperative Mild Pericardial Effusion Is Associated With Perioperative Complications In Elderly Patients Following Hip Fracture Surgery.

Background: The prevalence and prognostic value of mild pericardial effusion (MPE) has not been examined in patients undergoing non-cardiac surgery. Our study aimed to assess the frequency and prognostic value of MPE in elderly patients undergoing surgery for hip fracture. Methods: This is a single center, and retrospective study including elderly patients who underwent hip fracture surgery. The medical records of all patients, aged ≥65 years with femoral neck, intertrochanteric or subtrochanteric hip fracture undergoing surgery (intramedullary hip screw, sliding compression hip screw, hemiarthroplasty, or total hip arthroplasty) from June 2014 to June 2019 were analyzed. Patients with of multiple trauma and accidents were excluded. The MPE was defined as the presence of <10 mm pericardial effusion. The primary outcomes of the study were perioperative adverse medical events and length of stay in hospital. Results: A total of 462 patients (mean age 75.2 ± 11.7 years, and 53.5% female) were enrolled. MPE was detected in 72 patients (15.6%), and 62 patients (13.4%) experienced perioperative adverse medical events. Patients with MPE were older, had higher prevalence of diabetes, coronary artery disease, and heart failure, and had longer length of stay compared to patients without MPE. Univariate analysis showed a significant association between age, diabetes, coronary artery disease, American Society of Anesthesiologists status, MPE, and perioperative adverse events. After adjustment for age, demographics, and medical history, the presence of MPE remained as significant variable associated with perioperative complications (OR: 2.543, 95% CI: 1.173-3.469, p = 0.003). Conclusion: Our study is the first to demonstrate that the presence of MPE is associated with perioperative adverse events in elderly patients undergoing hip fracture surgery.

Efficacy of Pie-Crusting Technique on Soft Tissues in Distal Tibia and Fibula Fractures.

Distal tibia and fibula fractures are challenging injuries to treat as evidenced by the high rates of wound complications because of vulnerable soft tissue coverage. The aim of this study was to examine the effect on soft tissue complications of the pie-crusting technique when applied between 2 incisions in distal tibia and fibula fractures treated with open reduction and internal fixation. We reviewed 34 patients with distal tibia and fibula fractures treated between September 2014 and March 2017. The pie-crusting technique was performed during wound closure in 16 (47.06%) fractures (group 1) and classic wound closure was done in 18 (52.94%) fractures (group 2). The primary outcome was evaluated as the presence or absence of soft tissue complications such as superficial skin necrosis, deep skin necrosis, and deep infection. The mean age was 50.44 ± 13.51 (range 23 to 65) years in group 1 and 51.67 ± 14.49 (range 18 to 68) years in group 2. The mean follow-up time was 27.35 ± 9.02 (range 16 to 46) months. The mean surgery time after injury was 5.88 ± 3.5 (range 1 to 14) days in group 1 and 7.32 ± 4.25 (range 1 to 16) days in group 2. No soft tissue complications were seen in any patient in group 1. Five (27.77%) occurrences of superficial skin necrosis were observed in group 2. In 2 (11.11%) patients in group 2, deep necrosis and wound dehiscence occurred, and subsequent deep infection developed in 1 (5.55%) of these patients. The overall complication rate was higher in group 2 (p = .005). We believe that the pie-crusting technique is beneficial for wound closure in distal tibia and fibula fractures, because it reduces the tension of the skin and allows leakage of subcutaneous fluids.

Treatment results for acetabulum fractures using the modified Stoppa approach.

OBJECTIVES: The aim of this study was to evaluate the clinical and radiological results of the surgical treatment of acetabular fractures using modified Stoppa approach. METHODS: A total of 57 patients (mean age 37.8 years; range 15-84) who underwent surgical treatment for acetabular fracture with modified Stoppa approach from February 2013 to June 2016 were included into the study. The mean follow-up time was 28.1 months (range 24-35). The records were reviewed for fracture patterns, time to surgery, operative time, blood loss, reduction quality, and perioperative complications. Reduction quality was graded as anatomic, imperfect, or poor. The Harris Hip Score (HHS) and Merle d'Aubigné score were used for functional evaluation. RESULTS: Among the 63 acetabulum fractures of the 57 patients, 27 were associated with both columns, 12 were T-type fractures, 10 were transverse, 7 were anterior column/posterior hemitransverse, 5 were anterior column, and 2 were anterior wall fracture. A single surgeon performed all operations. Pfannenstiel incision was used in the first 19 cases while vertical midline incision in the remaining 38 cases. Average time to operation was 5.5 days, and supplemental lateral windows were used in 17 (29.8%) patients. Average blood loss and operation times were 660 mL and 152 min, respectively. Radiological outcomes were anatomic, imperfect, and poor in 52 (82.5%), 9 (14.2%), and 2 (3.2%) of the acetabulum fractures, respectively. Clinical outcomes at 2 years with HHS and Merle d'Aubigné scores were mean 86.6 (range 66-96) (Excellent in 27, good in 23, fair in 4, poor in 3 patient) and 16.7 (range 10-18) (Excellent in 25, very good in 18, good in 6, fair in 5, poor in 3 patient), respectively. There was a significant relation between the reduction quality and clinical outcome (p < 0.001), while there was no significant relation between the clinical outcome and the fracture type (p > 0.05). Iatrogenic external iliac vein damage was noted in 2 patients. Obturator nerve palsy was noted in 3 patients, who recovered spontaneously at mean time of 3.7 months (range 3-5). Rectus abdominus paralysis was noted in 2 of the 19 (10.5%) Pfannenstiel-incision patients but not in the vertical-incision patients. CONCLUSION: Our experience in 57 patients shows that satisfactory results can be obtained, even in bilateral fractures with vertical midline incision. LEVEL OF EVIDENCE: Level IV Therapeutic Study.

Effects of a lateral row anchor position on the suture holding strength of a double-row knotless fixation in rotator cuff repair.

OBJECTIVES: This study aims to evaluate the effects of anchor positions on the suture holding strength of a double-row knotless fixation in rotator cuff repair. MATERIALS AND METHODS: Four different double-row fixation techniques were assessed. In group 1, a 15-mm-wide mattress suture was fixed using a knotless lateral row anchor, horizontal to the shaft. In group 2, the medial sutures were fixed with a 5-mm more lateral anchor that was placed at 45° to the long axis of the humeral shaft. In group 3, different from group 2, medial sutures were fixed with a 30-mm mattress suture width. In group 4, the mattress sutures coming from the medial row anchors were fixed to the 10-mm more lateral row, vertical to the long axis of the humeral shaft. The specimens were cyclically loaded from 10 N to 30 N at 0.5 Hz for 50 cycles, and then loaded to failure. RESULTS: Group 4 had higher cyclic elongation values than group 1 (p=0.021) and group 3 (p=0.006). Group 1 had lower maximum load value than group 3 (p=0.011). Most of the specimens failed with suture ruptures. Unlike the other groups, none of the specimens in group 4 failed via a suture pull through the lateral anchor. CONCLUSION: A horizontal lateral row anchor positioned closer to the medial anchor resulted in less cyclic elongation when compared to a more vertically positioned lateral row anchor. The vertical or oblique positioning of the lateral row anchor did not result in any increase in the failure load value; however, the vertical placement prevented a suture pull through the lateral row anchor.

Late treatment of obstetrical brachial plexus palsy by humeral rotational osteotomy and lengthening with an intramedullary elongation nail.

To date, all the authors who have recommended external rotation osteotomy (ERO) in the late treatment of obstetrical brachial plexus palsy (OBPP), have neglected upper limb length discrepancy, which is an another sequelae of OBPP. In this paper, a new technique is reported for the late treatment of OBPP patients with upper limb length discrepancy, in which both humeral external rotation osteotomy (ERO) and lengthening are applied with an intramedullary elongation nail. With this technique, upper limb function is improved through re-orientation of the shoulder arc to a more functional range, and further improvements will be seen in the appearance of the upper limb with the elimination of length discrepancy. It is also advocated that there is a potentiating effect of the humeral lengthening on shoulder movements gained by ERO when the osteotomy is applied above the deltoid insertion, as this allows more lateralized placement of the deltoid insertion.

Aneurysmal bone cyst healing response with intramedullary lengthening nail.

We report the treatment process of a pediatric patient with deformity and shortening in the arm after a recurrent aggressive aneurysmal bone cyst (ABC) in the proximal humerus. The patient was treated with curettage of the lesion and lengthening on an intramedullary nail following an osteotomy just distal to the ABC. The period of lengthening was approximately 50 days. At the end of the treatment the lengthening goal was achieved without any neurovascular complication. There was a minimal loss in shoulder hyperabduction due to the deformity of the humeral head.

Femur can be lengthened over nail, along its mechanical axis : a modified lengthening over nail technique.

The theoretical risk of medialisation of the knee joint and the lateral shift of the lower extremity mechanical axis, due to achievement of lengthening along the anatomical axis is present in the process of lengthening with elongation nails and the "lengthening over nail" technique. With this new technique described in this study we aimed to prove that lengthening over nail can be performed along the mechanical axis of the femur. Six lower-limb models were used to perform three different lengthening techniques. In group 1, lengthening was achieved along the anatomical axis with an external fixator. In group 2, the clamps of the external fixator were adjusted at 6° to achieve lengthening along the mechanical axis. In group 3, eight different sized nails were applied with an external fixator (angle adjustable clamps were at 6°) to achieve lengthening along the mechanical axis by LON technique. Photographs were taken after each cm of lengthening and the distance from the mechanical axis line were measured. The modified LON technique described in this study provided lengthening along the mechanical axis. One of the main advantages of the procedure described in our study is the chance for reconsideration and revision of unforeseen angulations and malalignments, via the help of the distal angular adjustable clamps; during the time of the surgery for external fixator removal before application of the poller screws.