Editorial Commentary: Anatomic or Not, the Tunnel Will Get Wider!

In our experience, arthroscopic tunnel widening is one of the major complications after anterior cruciate ligament (ACL) reconstruction. Even though this complication doesn't require an acute correction or intervention, patients with failed ACL reconstruction along with tunnel widening may need a 2-stage revision in which we have to fill the gap in the tunnels first. Otherwise, this tunnel widening after ACL reconstruction doesn't affect the clinical outcomes of the primary surgery and it won't affect the success of the surgery in the aspects of clinical and functional outcomes.

Is internal fixation of the intertrochanteric fractures reliable option in patients with cognitive dysfunction?

The purpose of this study was to compare the results of hemiarthroplasty with those of treatment internal fixation devices for stable intertrochanteric fractures in patients with moderate and severe cognitive dysfunction. 155 patients were evaluated retrospectively. 54 patients were treated with proximal femoral nail (PFN), 57 with dynamic hip screw (DHS) and 44 were underwent hemiarthroplasty (HA). Activities of daily living (ADL) were evaluated with the Barthel Activity Index (BI) score and the Health Related Quality of Life (HRQoL) with the Euroquol-5D (EQ-5D) test. The BI scores in HA patients were found to be at significantly high compared to the PFN and DHS groups both at the one and two years. A significant difference was also found in the EQ-5D scores in favor of HA group at one year. The most common complications in internal fixation patients were malunion (7/54 for PFN, 9/57 for DHS group), fixation failure (8/54 for PFN, 12/57 for DHS group) and dislocation (10/44), deep infection (8/44) for HA group. The strong predictive variables on ADL in dementia patients were, duration time to surgery and pre-operative MMSE score. In conclusion, HA is the prefered treatment for stable intertrochanteric fractures but that the dislocation (10/44) and infection rates (8/44) are very high in dementia.

Using fibula as a reference can be beneficial for the tibial component alignment after total knee arthroplasty, a retrospective study.

PURPOSE: One of the important factors in a successful arthroplasty is component alignment. The primary objective of this study was to determine whether the fibular shaft reference technique is beneficial for the tibial component position on the postoperative plain radiograph after total knee arthroplasty. METHODS: A total of 42 patients between 2009 and 2011 were analysed retrospectively. The surgeon prepared the tibia using an extramedullary cutting guide and set the posterior tibial slope with respect to the fibular reference rod. In the postoperative radiographic measurements, a true anteroposterior and lateral radiograph of the lower leg covering the whole length of the tibia was used. RESULTS: Five patients were excluded as they did not meet the inclusion criteria, four patients were excluded due to improper radiographs and the study group was reduced to 33 patients and 35 knees. The mean preoperative tibiofibular angle was 2.1° ± 0.8°. The mean postoperative tibial sagittal angle measurements were 83.3° ± 1.4° (81°-86°). 33 (94 %) Knees gained the desired tibial sagittal angle within the desired alignment (5° ± 3°). The mean postoperative tibial coronal angle was 89.3° ± 1.5°. The tibial component coronal angle of two knees was more than 3 alignment from the neutral mechanical axis. CONCLUSION: The major clinical relevance of the technique described in the present study is cost-effectiveness, and it does not require any extra time or surgical equipment. This method can be used as an alternative choice for bulky extremities which is a cause of malalignment of the components. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Treatment of diaphyseal forearm atrophic nonunions with intramedullary nails and modified Nicoll's technique in adults.

OBJECTIVE: The aim of this study was to evaluate the outcome of tricorticocancellous autologous bone grafting with intramedullary forearm nails in the treatment of radius or ulna aseptic nonunion. METHODS: The study included 8 patients (mean age: 39 years; range: 19 to 55 years) who underwent plate-screw osteosynthesis for the treatment of nonunion (6 ulna, 2 radius) following forearm fracture. In all cases, the length of the applied tricortical graft was below 3 cm. Patients were evaluated using the visual analog scale, Grace and Eversmann scale and DASH score. Wrist flexion and extension and postoperative hand and forearm grip strength were assessed. RESULTS: Graft incorporation and union was completed at a mean of 22 (range: 18 to 28) weeks. No patient had nonunion, deep infection or radioulnar synostosis. Follow-up ranged from 18 to 52 months. Radiographic union was achieved in all patients. Mean visual analog scale pain score was 1 (range: 0 to 3). Grace and Eversmann ratings were excellent in 5 and good in 3 patients. Mean DASH score was 10.7 (range: 1.7 to 21.7) points. CONCLUSION: Intramedullary nailing and tricorticocancellous iliac bone block grafting appears to be a technically easy and reliable procedure that enables early postoperative rehabilitation in the treatment of nonunion of the forearm.

Ilizarov fixator combined with an intramedullary nail for tibial nonunions with bone loss: is it effective?

BACKGROUND: Treatment of tibial nonunion with bone loss is extremely difficult. A variety of techniques have been described, but each has shortcomings, in particular prolonged external fixation time as well as serious complications such as nonunion and infection. Accordingly, we developed a technique that seeks to reduce these complications by using a circular external fixator in addition to an intramedullary nail to achieve union, limb lengthening, and stability of the regenerated segment. DESCRIPTION OF TECHNIQUE: First, the pseudoarthrosis area is resected, and acute compression is continued until bone contact at the docking site was achieved. Then primary grafting is applied to the docking site using a graft harvested from the patient's iliac bone, and the predrilled nail holes localized on the middle segment of the tibia are locked with a free-hand technique. Finally, lengthening is performed to overcome the leg-length discrepancy with an external fixator. METHODS: Between 2008 and 2011, this technique was used to treat five patients with tibial nonunion with bone loss. All patients were available for a minimum of a 14-month followup (mean, 30 months; range, 14-58 months). General indications for the procedure were age older than 16 years, tibial nonunion with bone loss, and the absence of any psychiatric disorder. We evaluated external fixation time, external fixation index (defined as the duration of external fixation in months divided by the total amount of bone transported and/or the amount of lengthening in centimeters), and time to union on plain radiographs, clinical results using the Paley bone and functional assessment scores, and postoperative complications from chart review. RESULTS: The external fixation time was 4 months (range, 3-5 months), and the average external fixation index was 0.4 months/cm. The mean time to bone union was 4.6 months (range, 3.5-5.5 months). All angles were determined to be in the normal range. No patients developed refracture or malalignment either on the docking site or the osteotomy site. Paley bone evaluation results were excellent in all five patients, and Paley functional results were excellent in four and good in one. We observed 10 pin-site infections as minor complications, and one patient was left with a residual equinus deformity of 5° as a major complication according to the Paley classification. CONCLUSIONS: Our technique combining acute shortening and distraction osteogenesis had promising results for the treatment of tibial nonunion with bone loss in a small group of patients. However, future studies directly comparing available approaches to this difficult problem are required. Because this problem is uncommon, these studies will almost certainly require the cooperation of multiple large participating centers. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Paediatric lateral humeral condyle fractures: internal oblique radiographs alter the course of conservative treatment.

INTRODUCTION: At first presentation of paediatric humeral lateral condyle fractures, radiological methods such as computerised tomography, ultrasonography, magnetic resonance imaging, arthrography, and internal oblique radiography are used to determine stability. Very few studies show which radiological method should be used to evaluate displacement at follow-up for conservatively treated patients. This study aimed to show that internal oblique radiography is a simple, effective method to determine the subsequent development of fracture displacement in patients with an initially non-displaced or minimally displaced fracture. MATERIALS AND METHODS: In this retrospective study, 27 paediatric patients with non-displaced or minimally displaced (<2 mm) humerus lateral condyle fracture were evaluated by elbow anteroposterior radiograph. The degree of fracture displacement was evaluated by anteroposterior then by internal oblique radiographs. The first follow-up was made between the 5th and 8th day and thereafter at intervals of 7-10 days. RESULTS: Of the 27 patients identified with non-displaced or minimally displaced (<2 mm) fracture from the initial anteroposterior radiograph, 16 were accepted as displacement >2 mm as a result of the evaluation of the internal oblique radiography and underwent surgery. At follow-up, 2 of 11 patients were defined with displacement from anteroposterior and internal oblique radiographs and 4 from the internal oblique radiographs and underwent surgery. Conservative treatment was applied to 5 patients. CONCLUSIONS: Internal oblique radiography is the best imaging showing subsequent fracture displacement in initially non-displaced or minimally displaced humerus lateral condyle fractures. At the first week follow-up, anteroposterior and particularly internal oblique radiographs should be taken of conservatively treated patients.

New interlocking intramedullary radius and ulna nails for treating forearm diaphyseal fractures in adults: a retrospective study.

INTRODUCTION: The treatment goal for diaphyseal forearm fractures in adults is to restore axial and rotational stability. The treatment of these fractures with intrmaedullary locked nailing remains sparse. We therefore evaluated IM nails for treating forearm diaphyseal fractures in adults. METHODS: We retrospectively reviewed adult patients with isolated unilateral or bilateral fractures of the radius, ulna, or both, who were treated with closed or mini open reduction with a new IM nail between May 2008 and January 2012 and who were followed for a least 1 year. Patients with a Galeazzi fracture, a pathological fracture or patients with nonunion after previous surgeries were excluded. All patients were allowed full range of motion without any external support. Primary outcomes were Grace and Eversmann rating, Disabilities of the Arm, Shoulder and Hand (DASH) scores. RESULTS: The 43 enrolled patients (mean age, 37 years; 32 men) had 59 forearm fractures: 14 isolated radius fractures, 17 isolated ulna fractures (2 bilateral), and 28 fractures of both the radius and ulna. Mean time to fracture union was 13 weeks (range 10-14 weeks) for ulnar fractures and 12 weeks (range 10-13 weeks) for radial fractures. No patient had nonunion, deep infections, or radioulnar synostosis. Followup ranged from 12 to 44 months. Grace and Eversmann ratings were excellent in 38 patients and good in 5. Mean DASH score was 6.5 points (range 0-13.3). CONCLUSIONS: Intramedullary nailing of adult forearm diaphyseal fractures appears to be a good alternative to plate osteosynthesis. The advantages are short operative time, minimal invasive techniques, and sufficient stability in all planes that allows early motion without additional fracture support.

A comparison of the functional and radiological results of Paris plaster cast and ulnar gutter splint in the conservative treatment of fractures of the fifth metacarpal.

AIM: In the treatment protocol of fractures of the fifth metacarpal, closed reduction and immobilization is generally recommended. This study aimed to compare the radiological and functional results of short-arm plaster cast and a forearm U-splint. PATIENTS AND METHODS: Between January 2011 and June 2012, the study comprised a total of 122 cases with 64 (52.4%) in the cast group and 58 (47.6%) in the splint group. The cases were 92 (75.4%) males and 30 (24.6%) females with a mean age of 30.56 ± 12.27 years (range 10-66 years). Two groups were formed according to the surgical treatment plans of the two surgeons who were to follow up the patients. RESULTS: No statistically significant difference was found between the groups in terms of age, duration of the cast or splint and follow-up period (p > 0.05). The grip strength of Group A was determined as 90.38 ± 1.77% of the healthy side and Group B as 90.58 ± 1.65%. No statistically significant difference was seen between the groups in respect of grip strength (p > 0.05). The degree of dorsal angulation pre-application, post-application and after removal of the groups showed no statistically significant difference between the groups (p > 0.05). CONCLUSION: No superiority was seen in the clinical and radiological results of the two different treatment protocols applied to fractures of the fifth metacarpal. However, when the complications created by a plaster cast and pressure wounds are taken into consideration, the application of a short-arm U-splint can be said to be a better option.

Treatment of isolated diaphyseal fractures of the radius with an intramedullary nail in adults.

BACKGROUND: The goal of the radius diaphysis fractures in surgical treatment is restoration of bone length, rotation correction and to secure fixation that allows early mobilization. The purpose of this study is evaluating the results of intramedullary (IM) radius nail for the treatment of isolated adult diaphyseal fractures of the radius. MATERIALS AND METHODS: We retrospectively reviewed adults with isolated fractures of the radius, who were treated with closed or mini open reduction with a IM radius nail between May 2008 and November 2011 and who were followed for a least 1 year. Patients with a Galeazzi fracture, a pathological fracture, or patients with nonunion after previous surgeries were excluded. All patients were allowed full range of motion without any external support. Primary outcomes were Grace and Eversmann rating, Disabilities of the Arm, Shoulder and Hand (DASH) scores. RESULTS: Twenty-three enrolled patients (mean age 34 years; 17 men) had 23 isolated radius fractures. Mean time to fracture union was 12 weeks (range 10-13 weeks) for radius fractures. No patient had nonunion, deep infections, or radioulnar synostosis. Follow-up ranged from 12 to 42 months. Grace and Eversmann ratings of 21 patients were excellent or good, and 2 patients were medium. Mean DASH score was 4.2 points (range 0-13.3). CONCLUSIONS: Our experience indicates that this new IM radius nail may be considered as an alternative to plate osteosynthesis for fractures of the radius diaphysis in adults. IM nailing of radius fractures provides reliable bony union and excellent postoperative clinical results in adults.

[Measurement of screw length through drilling technique in osteosynthesis of the proximal humerus fractures]. / Proksimal humerus kiriklarinin osteosentezinde vida boyunun sondaj teknigi ile ölçülmesi.

OBJECTIVES: This study aims to investigate the efficacy of screw length measurement through drilling technique on the reduction of intraarticular screw penetration and fluoroscopy time in osteosynthesis of proximal humerus fractures. PATIENTS AND METHODS: Between January 2008 and June 2012, 98 patients (34 males, 64 females; mean age 64.4 years; range 35 to 81 years) who underwent osteosynthesis using locking anatomical proximal humerus plates (PHILOS) in our clinic with the diagnosis of Neer type 2, 3 or 4 were included. Two different surgical techniques were used to measure proximal screw length in the plate and patients were divided into two groups based on the technique used. In group 1, screw length was determined by a 3 mm blunt tipped Kirschner wire without fluoroscopic control. In group 2, bilateral fluoroscopic images for each screw at least were obtained. RESULTS: Intraarticular screw penetration was detected in five patients (10.6%) in group 1, and in 19 patients (37.3%) in group 2. The mean fluoroscopic imaging time was 10.6 seconds in group 1 and 24.8 seconds in group 2, indicating a statistically significant difference. CONCLUSION: Screw length measurement through the drilling technique significantly reduces the intraarticular screw penetration and fluoroscopy time in osteosynthesis of proximal humerus fractures using PHILOS plates.

Ipsilateral distal femoral and proximal tibial epiphyseal growth plate injury: a case report.

INTRODUCTION: Both the isolated distal femoral epiphysiolysis and the isolated proximal tibial epiphysiolysis are the least common epiphyseal injuries. Even though they are uncommon, they have a high incidence rate of complications. CASE PRESENTATION: We present a case with Gustilo-Anderson grade 3b open and Salter-Harris type 1 epiphysiolysis of the distal femur and proximal tibia caused by a farm machinery accident. The patient was a 10-year-old boy, treated by open reduction and internal fixation. CONCLUSION: Although distal femoral and proximal tibial growth plate injuries are rarely seen benign fractures, their management requires meticulous care. Anatomic reduction is important, especially to minimize the risk of growth arrest and the development of degenerative arthritis. However, there is a high incidence of growth arrest and neurovascular injury with these type of fractures.

Minimal invasive midvastus versus standard parapatellar approach in total knee arthroplasty.

OBJECTIVE: The aim of this study was to compare the short-term results of total knee arthroplasty (TKA) surgeries performed with minimally invasive mini-midvastus (MMV) incision and the standard medial parapatellar technique (ST). METHODS: Twenty patients (18 males, 2 females; mean age: 67.25±6.70) operated with the ST and 19 patients (4 males, 15 females; mean age: 64.53±7.53) operated with the MMV approach were retrospectively evaluated. The surgery time, blood loss, time to straight leg raise (SLR) postoperatively, range of motion (ROM) and Knee Society (KSS) score and Hospital for Special Surgery (HSS) score were compared between the groups. Radiological evaluation was made with standing orthoroentgenographs both pre- and postoperatively. Mean follow-up time was 29.4±8.2 months in the ST and 17.7±11.1 months in the MMV group. RESULTS: In the early postoperative period (10th day), the MMV group was significantly better than the ST group in terms of ROM. Time to SLR and blood loss values were also significantly better in the MMV group. However, there was no significant difference between the groups after the sixth month, for ROM, KSS and HSS values (p>0.05). Surgery time was significantly longer (with a mean difference of 22 minutes) in the MMV group. Radiological examination revealed ideal alignment in both groups. No deep or superficial infection was detected. Two patients in the MMV group had skin problems which healed after clinical follow-up. CONCLUSION: Our results suggested that functional results of TKAs performed via the MMV approach are better in the first six months when compared to those of the ST.

Mid-term results of calcaneal plating for displaced intraarticular calcaneus fractures.

BACKGROUND: The radiological and functional results of surgical treatment in intraarticular calcaneal fractures are presented in this study. METHODS: 27 feet of 26 patients with displaced intraarticular fractures were treated surgically in our clinic between November 2003 and May 2009. Twenty-one patients were male (81%), and 5 were female (19%). The average age was 29.2 (range, 18-61 years) at the time of the surgical treatment. Open reduction internal fixation was performed by using a calcaneal plate. RESULTS: The results were evaluated according to the Maryland foot scores and Creighton-Nebraska scores. The mean follow-up period was 34.4 months (range, 19-85 months). The radiological evaluation was made according to the mean value changes of Böhler and Gissane angles after injury and at the last follow-up. Except for 3 patients with Sanders type 4 fractures, good results were obtained with surgical treatment. CONCLUSION: We conclude that open reduction and internal fixation methods yield a reasonable outcome, even in patients with Sanders type 4 intraarticular fractures of the calcaneus.

The mid-term results of treatment for tibial pilon fractures.

BACKGROUND: In this report, the surgical treatment results of distal tibia (pilon) fractures are analyzed radiologically and clinically. METHODS: Between 2002 and 2009, 32 feet of 31 patients (25 males, 6 females; mean age 46 years; range 17 to 72 years) who were treated surgically for tibial pilon fractures were evaluated. Open reduction and internal fixation were applied to 24 and external fixation to 8 fractures. The patients were evaluated according to the Teeny-Wiss functional ankle score, and overall assessment of reduction was calculated radiographically according to the criteria of Ovadia and Beals. RESULTS: While excellent results were achieved in 9 (47.4%) type 2, 5 type 1 (26.3%), and 5 (26.3%) type 3 fractures, fair/ poor outcomes were obtained in 9 (69.2%) type 3 and in 2 (15.4%) types 1 and 2 fractures each (p<0.015). Compared to the external fixation application, a statistically significantly higher number of excellent and good outcomes were obtained with open reduction internal fixation application (n=3, 15.8% vs n=16, 84.2%, respectively; p<0.05). CONCLUSION: If the principles of atraumatic soft tissue dissection, anatomic reduction of the joint face, stable fixation, and early mobilization of the patient are complied with in the surgical treatment of pilon fractures, successful results can be achieved. However, in type 3 fractures, even if these principles are complied with, post-traumatic arthritis is inevitable.