A new configuration of lateral-pin fixation for pediatric supracondylar humeral fracture: A biomechanical analysis.

OBJECTIVE: The aim of this study was to biomechanically compare a new lateral-pinning technique, in which pins engage the medial and lateral columns of the distal humerus in a divergent configuration in both the axial and sagittal planes instead of the coronal plane, with the cross-pin, and with 2 and 3 coronally divergent lateral-pin techniques in a synthetic humerus model of supracondylar humerus fractures. METHODS: Thirty-six identical synthetic models of the humerus simulating a standardized supracondylar humerus fracture were included in this study. They were divided into 4 groups based on the pin configuration of fixation: the new 3-lateral pin-fixation technique (group A), 2 crossed pins (group B), 3 divergent lateral pins (group C), and 2 divergent lateral pins (group D). Each model was subjected to combined axial and torsional loading, and then torsional stability and torsional stiffness (Nmm/°) were recorded. RESULTS: Group A had greater rotational stability than groups C and D but had no statistically significant additional rotational stability compared with group B (P=.042, P=.008, P=.648, respectively), whereas group B had greater rotational stability than only group D (P=.020). Furthermore, group A demonstrated higher internal rotational stiffness compared with groups C and D (P=.038, P=.006, respectively). Group B had better internal rotational stiffness than group D (P=.015). There was no significant difference in internal rotational stiffness between groups A and B (P=. 542), groups B and C (P=.804), and groups D and C (P=.352). Although no statistically significant differences existed between groups A and B, the modified pin configuration exhibited the highest torsional stability and stiffness. Group D showed the lowest values in all biomechanical properties. CONCLUSION: This study has shown us that this new lateral-pinning technique may provide torsional resistance to internal rotational displacement as strong as the standard technique of crossed-pin configuration of fixation. Furthermore, with this new pin configuration, greater torsional resistance can be obtained than with either the standard 2- or the standard 3-lateral divergent pin configuration. Cite this article as: Bilgili F, Demirel M, Birisik F, Balci HI, Sunbuloglu E, Bozdag E. A new configuration of lateral-pin fixation for pediatric supracondylar humeral fracture: A biomechanical analysis. Acta Orthop Traumatol Turc., 2023 10.5152/j.aott.2024.21091 [Epub Ahead of Print].

Augmentation with a non-vascularized autologous fibular graft for the management of Cierny-Mader type IV chronic femoral osteomyelitis: a salvage procedure.

PURPOSE: The study aimed to evaluate preliminary clinical and radiographic results of patients with Cierny-Mader type IV chronic femoral osteomyelitis and augmented with a non-vascularized fibular autograft as a salvage procedure because of the poorly regenerated new bone after bone transport over an intramedullary nail (BTON). METHODS: Patients diagnosed with CM type IV chronic femoral bone infection and treated with BTON procedure between 2003 and 2020 were retrospectively reviewed. Seven patients were included in the study whose distraction gap was poorly regenerated and then augmented with a non-vascularized fibular autograft. A three-stage treatment was administered. First, the infection was eradicated. Second, BTON was performed. Third, the poorly regenerated distraction gap was augmented with a fibular autograft before removing the external fixator (EF). Clinical and radiological results were evaluated based on the criteria described by Paley-Maar and Li classification. RESULTS: The mean patient age was 52 years. The mean treatment time was 24.8 months, with a mean femoral lengthening of 12.6 cm. The mean EF and bone healing indexes were 0.57 months/cm and 0.8 months/cm, respectively. The mean length of the fibular graft was 13 cm. The bone healing of new bones was achieved in all patients with good quality after grafting. Functional scores were excellent in four patients. No patients experienced any sequelae. CONCLUSIONS: Non-vascularized fibular autograft augmentation may be an effective salvage procedure for poorly regenerated new bone after BTON to manage chronic femoral bone infection.

Does the technique of limb lengthening affect physeal growth in patient with achondroplasia? Comparison of the simultaneous and consecutive tibia and femur lengthening with external fixators.

We aimed to retrospectively investigate and compare patients who underwent bilateral simultaneous and consecutive lengthening surgery of the femur and tibia in terms of the effect on physeal growth. We hypothesize that compared with the sequential lengthening technique, simultaneous lengthening of the bilateral femur and tibia affects physeal growth to a greater extent. Twenty-six patients with achondroplasia who operated in our clinic between 1995 and 2015 for limb lengthening were included in the study. Fourteen patients with bilateral lengthening of the femur and tibia at the same time were named as simultaneous bilateral lengthening (SBL). Twelve patients with bilateral lengthening of the femur and then bilateral tibia lengthening in other sections or vice versa, at a different time was named consecutive bilateral lengthening (CBL). All patients were followed until at least 18 years old. The physeal arrest was measured with predicted final length at the first visit (investigated with the multiplier method), the total amount of lengthening, and final clinical, and radiological length. Mean limb lengthening was 145 mm (48.5%) and 151 mm (46.6%) for simultaneous and consecutive groups respectively. For lower extremity length, the first group reached 527.6 mm while the expected was 447.3 mm. Considering 151 mm lengthening, the mean growth disturbance for the SBL group was 70.7 mm and for the CBL group was 47.5 mm. For total height comparing between two groups, disturbance for height was 80.5 mm and 65.4 mm, respectively. Although there was no statistical difference, simultaneous bilateral femoral and tibial lengthening has more physiological physeal disturbance effects than consecutive lengthening in patients with achondroplasia.

Plate fixation after lengthening with an external fixator in patients with achondroplasia : A comparative study between two centers.

BACKGROUND: This study compared internal fixation with a plate after lengthening (PAL) with an external fixator with the conventional method (CM) in terms of radiologic and clinical outcomes in the lower extremities of patients with achondroplasia. METHODS: In this study 20 patients (50 lower extremity long bones) who underwent PAL or CM were divided into 2 cohort groups. The amount of lengthening, percentage lengthening, external fixator index (EFI), external fixator time, Li regeneration index, complication rate, and knee range of motion (ROM) were compared between the groups. RESULTS: The median age was 9.4 years (range 6-16 years) in the PAL group and 12 years (range 9-16 years) in the CM group (p = 0.01). Males comprised 80% of the patients in the PAL group and 47% of the patients in the CM group (p = 0.02). The median amount of lengthening in the PAL and CM groups was 7.5 cm (range 5.5-9.5 cm) and 6.0 cm (range 5.5-9.0 cm), respectively (p < 0.01). The median percentage of lengthening in the PAL and CM groups was 44.6% (range 20.0-70.1%) and 43.0% (range 20.5-57.3%), respectively (p = 0.01). The median external fixator time in the PAL and CM groups was 127 days (range 94-185 days) and 180 days (range 105-355 days), respectively (p < 0.01). The median EFI in the PAL and CM groups was 21 days/cm (range 10-33 days/cm) and 27 days/cm (range 15-59 days/cm), respectively (p < 0.01). The Li regeneration index was 3 (interquartile range, IQR 2-4) in both groups (p = 0.2). The total complication rate was similar between the groups. CONCLUSION: In patients with achondroplasia, after lengthening with an external fixator, internal fixation with a plate can be a reliable alternative to the conventional method. LEVEL OF EVIDENCE: Level III therapeutic.

The Relationship Between Limb Lengthening Rate and Callus Quality in Patients with Achondroplasia.

Objectives: This study investigated the effect of the femur, tibia, and humeral lengthening rate in patients with achondroplasia and regenerated bone quality. Methods: The records of the patients with achondroplasia who underwent limb lengthening surgery for both upper and lower extremities between 2002 and 2019 were retrospectively reviewed. Bone formation regeneration was evaluated in each segment at anteroposterior and lateral radiographs and the callus quality was determined at the first month of the consolidation period according to Li's classification system. Results: This study included 42 (28 females and 14 males), 38 (26 females and 12 males), and 17 (11 females and 6 males) patients with bilateral femoral, bilateral tibial, and bilateral humeral lengthening. The mean lengthening rate was 0.920 ± 0.23 (range, 0.53-1.67), 0.813 ± 0.17 (range, 0.51-1.26), and 1.02 ± 0.26 (range, 0.58-150) mm/day in the femoral, tibial, humeral groups, respectively. In the femoral group, 75% femur with good morphological quality, 56.6% good morphological quality in tibial group and 55.9% good morphological quality in humeral group. Statistically significant relationships were found between femoral lengthening rate and callus quality (p < 0.001; r = 0.454). However, no significant correlation was found in the humeral and tibial groups. Moreover, the sensitivity and specificity of the lengthening rate for obtaining good morphological quality callus were 72% and 80%, respectively, with an optimum diagnostic cutoff value of 0.976 mm/day for femoral lengthening. Conclusions: A higher-rate good morphological callus was obtained in femoral lengthening compared with tibia and humerus in patients with achondroplasia.

Limb salvage results of Gustilo IIIC fractures of the lower extremity.

This study aims to present our results for limb salvage in Gustilo IIIC open fractures of the femur and tibia. 92 patients with Gustilo IIIC fractures operated in our clinic between January 2000 and March 2016 were retrospectively evaluated. Demographic data, ischemia time, method of arterial repair, means of primary and secondary fixation, time to amputation, complications, and final VAS scores were recorded. The difference between the primary amputation rates of tibia and femur fractures was not statisti- cally significant (18% vs 21%, p>0.05). The difference between the secondary amputation rates of tibia and femur fractures was not significant (16% vs 27%, p>0.05). All secondary amputations were done within the first month during the initial hospital stay. Overall limb salvage rate was 69% for Gustilo IIIC fractures of the femur and 58% for Gustilo IIIC fractures of the tibia. The overall limb salvage rate was not significantly different between the two groups (p>0.05). At the final follow-up, patients in the limb salvage group had average VAS scores of 4.3 (femur) and 4.7 (tibia). The decision between amputation versus limb salvage remains a difficult decision that should be jointly made by the treating physicians and the patient.

Effect of lengthening speed on the quality of callus and complications in patients with congenital pseudarthrosis of tibia.

PURPOSE: This study aims to evaluate the effect of lengthening speed on the quality of callus and complications during distraction osteogenesis and describe an optimal lengthening speed in patients with congenital pseudarthrosis of tibia (CPT). METHODS: Twenty-seven patients with CPT with a minimum follow-up of 36 months who underwent limb lengthening surgery between 1997 and 2016 with external fixator only were included in this study. All patients underwent lengthening procedures after achieving complete bone union in this study. Regenerate quality is evaluated according to the Li classification on the X-ray taken one month after the end of the distraction period. Complications were noted in post-operative follow-up period. Receiver operator characteristics (ROC) curve analysis was performed to obtain optimal lengthening speed for these patients. RESULT: The mean age at the time of surgery was 5.74 years. The mean lengthening speed was 0.596 mm/day. Follow-up period of 136.14 months with a mean lengthening period of 92.4 days. Mean amount of lengthening was 5.44 cm for patients with CPT. Total rate of callus with good morphological quality was calculated as 66%. According to ROC analysis, optimal cut-off values of lengthening speed for the obtaining good morphological quality callus was 0.564 mm/day for tibial lengthening in CPT. There was a significantly positive correlation between complication rate and lengthening speed for each group. CONCLUSION: We recommend a mean lengthening rate of 0.56mm/day for the lengthening procedures with external fixator in patients with CPT who had complete bone union at the area of pseudarthrosis.

Quality of Life Evaluation Following Limb Lengthening Surgery in Patients with Achondroplasia.

BACKGROUND: The primary objective of this study was to evaluate the quality of life following limb lengthening surgery in patients with achondroplasia. The complications and different lengthening techniques have and effects on mid-term results were also investigated. METHODS: We performed a retrospective, multicenter study by evaluating the records of patients with achondroplasia operated in our clinic between 1999 and 2014 for limb lengthening with a minimum follow-up of 3 years. Forty nine patients were underwent bilateral lower limb lengthening surgery and 21 of 49 patients underwent bilateral humerus lengthening surgery. Patients were evaluated by the Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales to assess the health-related quality of life (HRQOL) of children. Twenty patients with achondroplasia who had no lengthening surgery history were also evaluated with the PedsQL score as the control group. RESULTS: The average age at the time of first surgery was 6.17 years. The average follow-up period was 100.2 months. The average age at the time of study 14.70 ± 2.44 (11-18) years. There were significant differences between the patients with humeral lengthening and patients who did not undergo humeral lengthening in all scores. Transient complications had minimal effects on scores. Although all scores in the operated group were higher than non-operated patients with achondroplasia, there were no significant differences. CONCLUSION: Quality of life was significantly improved as a result of humerus lengthening surgery of patients with achondroplasia, despite minor complications compared with Lower limb lengthening surgery. LEVEL OF EVIDENCE: Level III, case control study.

Combined Technique for the Treatment of Infected Nonunions of the Distal Femur With Bone Loss: Short Supracondylar Nail-Augmented Acute Shortening/Lengthening.

OBJECTIVE: To evaluate a combined technique for treating distal femoral bone defects after debridement of osteomyelitis, using an external fixator together with a short supracondylar nail. DESIGN: Retrospective study. SETTING: Single tertiary referral center. METHODS: Between 2003 and 2018, 23 patients with a mean age of 37.2 years (26-56) underwent surgery with the same technique to manage postdebridement defects in the distal femur due to osteomyelitis. This involved acute shortening and intramedullary fixation of the defect site, together with relengthening from a proximal osteotomy using simultaneous external fixation. Radiographic union, range of motion of the hip and knee, external fixation time and external fixation index, and limb length discrepancy were assessed. RESULTS: The mean follow-up was 51 months (18-192). Union was achieved in all patients without recurrence of infection during this follow-up period. The mean knee flexion was 120 degrees, and the mean extension deficit was 5 degrees at final follow-up. The mean limb length discrepancy improved from 5.5 cm (3-7) to 0.5 cm (0-2). The mean external fixation index was 29.2 d/cm (20-50), and the mean external fixation time was 115 days (90-150). Radiographic scores were excellent in 15 cases, good in 6, and fair in 2. Functional scores were excellent in 14 cases, good in 7, and fair in 2. CONCLUSION: This combined strategy was an effective method for treating distal femoral segmental bone defects after debridement of osteomyelitis, with a high rate of union and acceptable complication rates. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Prognostic factors affecting survival of patients with intertrochanteric femoral fractures over 90 years treated with proximal femoral nailing.

OBJECTIVE: This study aimed to analyze the prognostic factors affecting the survival of patients over 90 years with intertrochanteric fractures treated with proximal femoral nailing. MATERIALS: Records of 53 patients over 90 years old treated in our clinic between 2009 and 2018 for intertrochanteric fractures with proximal femoral nailing were retrospectively reviewed. Neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) were analyzed for validity as prognostic factors. Kaplan-Meier test was used to estimate overall survival. A multivariate Cox algorithm was used to determine independent factors associated with survival. The minimum follow-up duration was one year. RESULTS: The average age at the time of surgery was 92.8 years. There were 39 women and 14 men. The right femur was involved in 29 (54.7%) patients and the left in 24 (45.3%) patients. At the time of this study, 32 (60.3%) patients were deceased. There were 21 (39.7%) surviving patients with a mean survival of 41.2 months (range 12-113). Survival rates at first month, 6 months and 1 year after surgery were 90.6%, 88.6% and 86.7%, respectively. The mean survival after surgery was 29.6 (2 days-95 months) months for deceased patients. Among all the parameters, ASA score and delay to surgery were independently associated with worse overall survival. CONCLUSION: An ASA score of 4 increased mortality by a factor of 26 and delay to surgery increased mortality by a factor of 1.3. Both were prognostic factors influencing overall survival.

Prevalence of anterior knee pain after patellar retention total knee arthroplasty: Comparison of patients with rheumatoid arthritis versus primary osteoarthritis.

OBJECTIVE: The aim of this study was to investigate whether there is an increased risk of anterior knee pain (AKP) after total knee arthroplasty (TKA) without patellar resurfacing in patients with rheumatoid arthritis (RA) versus primary osteoarthritis (OA). METHODS: This study was a retrospective review of 388 patients (577 knees) who underwent TKA without patellar resurfacing between 2003 and 2011, with a minimum of 5 years of follow-up. Patients were divided into two groups: Group OA (273 knees of 206 patients; 83 males, 123 females; mean age: 64.4 (47-87) years) and Group RA (304 knees of 182 patients; 92 males, 90 females; mean age: 50.7 (21-72) years). In the clinical evaluation, the knee range of motion (ROM) and several outcome measures such as The Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and International Knee Documentation Committee (IKDC) scores were used preoperatively and at the final follow-up visit. The quality of life was measured using Short Form (SF)-36 MCS and PCS scores. The primary outcome was the frequency and severity of patient-reported AKP. The AKP Scale was used to determine the severity of AKP. RESULTS: The IKDC raised from 21.62 (range, 13-29.9) preoperatively to 85.1 (range, 80-88) for group OA and from 21.8 (range, 13-29.9) to 85.2 (range, 81-88) for group RA (p < 0.001). The mean KSS improved from 28.35 (range, 22-38) preoperatively to 90.04 (range, 88-95) for group OA and from 21.9 (range, 18-35) preoperatively to 89.7 (range, 86-95) for group RA. The mean WOMAC increased from 20.61 (range, 17.4-24.2) preoperatively to 95.7 (range, 90.9-97.7) for group OA (p < 0.001) and from 20.2 (range, 16.7-24.2) preoperatively to 95.8 (range, 90.9-98.5) for group RA (p < 0.001). The mean ROM improved from 80.14° (range, 55°-130°) preoperatively to 113.17° (range, 95°-140°) in group OA (P = 0.003) and from 73.4° (range, 10°-130°) to 112.8° (range 90°-140°) in group RA (P = 0.003) postoperatively. The frequency of AKP was 8% in Group OA and 7% in Group RA (p = 0.27). For patients with AKP, the mean AKP Scale was 92.74 (range, 84-98) in Group OA and 93.39 (range, 82-98) in Group RA (p = 0.3). CONCLUSION: After TKA without resurfacing the patella, patients with RA were determined to have a similar risk for AKP as those with OA. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

Concomitant rhomboid-shaped tibiae and fibulae, finger-like projections, and orthopedic management in a new variant of nievergelt syndrome: A case report.

INTRODUCTION: The rare Nievergelt syndrome (NS) is the most severe form of mesomelic dysplasia and is characterized by disproportionate shortness of the limbs. The aim of this case report was to describe the clinical and radiological features of a rare case of NS. PRESENTATION OF CASE: Here we describe a female patient originally presenting with bilateral hand, lower leg, and foot deformities at the age of 10 years old. In addition to the characteristic features of NS, this patient presented with finger-like projections on her heels, bilateral hand anomalies, and atypical facial features. She underwent concomitant bilateral tibial lengthening and deformity correction using external fixators due to severe bilateral lower leg deformities with shortness. At 10 years of age, this patient was able to walk independently with significant improvement in her ambulation. DISCUSSION: There is a clear gap in the literature regarding the orthopedic management of mesomelic limb deformities due to NS. No studies have been designed to illustrate surgical planning in the management of orthopedic deformities in this rare syndrome. CONCLUSION: Limb lengthening and deformity correction using an external fixator can be considered as a salvage method or alternative to amputation for patients with severe mesomelic limb deformities due to NS.

Long-term results and comparison of the three different high tibial osteotomy and fixation techniques in medial compartment arthrosis.

BACKGROUND: The purpose of this study is to report and analyze the long-term outcomes of the patients who underwent high tibial osteotomy (HTO) with three different techniques for the treatment of medial compartment arthrosis. METHODS: A total of 187 patients (195 knees) who underwent HTO between 1990 and 2010 were retrospectively evaluated. Eighty-eight knees, opening-wedge osteotomy with Puddu plate (group A); 51 knees, transverse osteotomy below the tubercle with external fixator (group B); and 29 knees, closing-wedge osteotomy with staple fixation (group C) were included in the study. The patients (mean age 44.9 ± 10.6 years, mean follow-up of 12.4 ± 3.2 years) were called for final controls and survival rates of the knees, and functional evaluations of the patients were performed using Knee Society Score (KSS) and Hospital for Special Surgery (HSS) knee score assessments. RESULTS: In the comparison of the three groups, there were no differences regarding the mean age, preoperative arthrosis levels, or preoperative deformity analyses (n.s.). The main finding of these comparisons showed that the closing-wedge osteotomy has the greatest lateralization effect on mechanical axis deviation (MAD) (p = 0.024), the greatest valgization effect on medial proximal tibial angles (MPTA) (p = 0.026), and the lowest posterior tibial slope (PTS) angles (p = 0.032) in comparison to the other groups. There were no functional differences between the three groups in the long-term assessment of patients with KSS and HSS knee scores. According to the Kaplan-Meier survival analysis, the probability of the survival of the native knee joint after HTO was 93.4% in 5 years and 71.2% in 10 years in our study group. During the follow-up of the 168 knees, revision surgery with total knee replacement was needed in 27 knees (16%). The mean time from HTO to total knee replacement was 8.9 years in these patients. CONCLUSIONS: HTO has acceptable long-term clinical and functional results that should not be underestimated by orthopedic surgeons under pressure to perform arthroplasty operations.

Effects of NSAIDs and hydroxyapatite coating on osseointegration.

PURPOSE: The aim of our study is to investigate the bone ongrowth of two different alternative surfaces and the effect of nonsteroidal anti-inflammatory drugs (NSAIDs) on osseointegration. METHODS: Hips of 40 New Zealand white rabbits were operated bilaterally. Hydroxyapatite (HA)-coated titanium rods were implanted into the right femur, and grit-blasted titanium rods were implanted into the left femur. They were divided into three groups. At the end of 8 weeks, both femora of the rabbits were removed and investigated biomechanically and histologically. RESULTS: HA-coated implants had a significantly better failure load and "percentage of bone-implant contact" than grit-blasted implants. There was no significant difference between the medication groups as a result of the biomechanical and histologic investigations. CONCLUSIONS: Our results indicate that NSAIDs did not have any negative effect on the osseointegration. HA-coated implants may provide more tensile strength and greater bone-implant contact rate in comparison with grit-blasted implants.

Double intertrochanteric osteotomy for trochanteric overgrowth and a short femoral neck in adolescents.

PURPOSE: To review the outcome of Wagner double intertrochanteric osteotomy for trochanteric overgrowth and a short femoral neck in 7 adolescents. METHODS: Records of one male and 6 females aged 15 to 20 years who underwent modified Wagner osteotomy for trochanteric overgrowth and a short femoral neck by a single senior surgeon were reviewed. The diagnoses were coxa vara (n=2), developmental dysplasia of the hip (n=3), Leg-Calve-Perthes (n=1), and proximal femoral focal deficiency (n=1). Radiological indication for double intertrochanteric osteotomy included a neck-shaft angle (NSA) <120º or a centre trochanter distance (CTD) <28 mm. Function was evaluated using the Children's Hospital Oakland Hip Evaluation Scale (CHOHES). The articulotrochanteric distance (ATD), CTD, NSA, and the distance between the centre of the femoral head and the centre of the acetabulum (MZ) were measured on radiographs. RESULTS: The mean follow-up duration was 61 (range, 28-86) months. The ATD improved from 16±11.5 mm to -6.3±10.2 mm (p=0.018), the CTD from 27.9±3.5 mm to 36.4±7.1 mm (p=0.018), the NSA from 112º±24.4º to 131º±16º (p=0.028), the MZ from 12.7±6.5 mm to 7.7±4.2 mm (p=0.028), and the CHOHES score from 62.1±8.7 to 84±9.6 (p=0.017). One patient had delayed union. Two patients had persistent Trendelenburg gait. Two patients declined second-stage surgery for acetabular dysplasia after solving the femoral side problems at the first stage. One of them developed hip arthrosis. CONCLUSION: Double intertrochanteric osteotomy is a viable treatment option for adolescents with trochanteric overgrowth and a short femoral neck.

Surgical Treatment of an Infected Nonunion of the Middle Third of the Femur Associated with Femoral Shortening in a Hemophilia Patient.

The management of nonunion and limb length discrepancy has remained a constant challenge in hemophilic patients. In this study, we aimed to present the treatment of femur infected nonunion and limb length discrepancy in a twenty-seven-year-old patient with hemophilia type A. A 27-year-old male patient with hemophilia type A referred to our institution for the treatment of right femur infected nonunion and 10 cm shortness of the femur. Resection of the nonunion site and bone-to-bone fixation with autologous bone grafting were performed. Compression to the pseudoarthrosis site and distraction from new osteotomy site were applied with the unilateral external fixator. Union was achieved, and 6 cm lengthening was obtained according to the initial length. Patient was followed up for 7 years. After this treatment, the patient is able to walk with full weight bearing on the affected extremity with 4 cm shortening which is compensated by the heel lift. The results of this case indicate that limb lengthening and treatment of nonunion with the external fixation could be reliable and effective method for hemophilic patients.

Treatment of infected nonunion of the juxta-articular region of the distal tibia.

OBJECTIVE: The purpose of this study was to summarize our clinical results with distraction osteogenesis for the treatment of infected tibial nonunion around the ankle joint. METHODS: Between 1994 and 2009, 13 patients with a mean age of 50 years (range: 27-79 years) underwent tibial reconstruction for the treatment of infected nonunion of the distal tibia, with a mean bone loss of 4.8 cm (range: 1-7 cm). Lengthening over an intramedullary nail as a second procedure was used in 2 patients, bifocal compression and distraction technique in 5 cases, compression with Ilizarov external fixator in 5 cases, and Taylor Spatial Frame (TSF, Smith Nephew, Memphis, TN, USA) in 1 case. At final follow-up, functional and radiographic results were evaluated according to Paley's bone and functional healing criteria. RESULTS: Mean duration of follow-up was 36 months. Mean external fixation time was 198 days, and mean external fixation index was 29 days/cm. According to Paley's bone healing criteria, there were 10 excellent, 2 good, and 1 poor result(s); additionally, according to Paley's functional healing criteria, there were 5 excellent, 6 good, and 2 fair results. There were 11 problems, 5 obstacles, and 1 sequel according to Paley's classification of complications. There was 1 persisting nonunion, which underwent revision with a retrograde intramedullary nail. CONCLUSION: External fixator and/or combined treatment are effective and reliable methods to treat infected nonunion of the distal tibia. Every patient should be evaluated according to their infection level and bony defects for reconstruction.

Knee Arthrodesis in Persistently Infected Total Knee Arthroplasty.

The reported incidence of infection in total knee arthroplasty (TKA) varies from 0.5 to 15%. The most common indication for knee arthrodesis is persistent infection after repeated staged knee replacement. The purpose of this study is to investigate the success of fusion with monoplanar fixators and eradication rates of infection, and to evaluate the satisfaction of patients who underwent a last-resort TKA due to infection.This is a retrospective review of infected knee arthroplasties that were treated with knee arthrodesis using unilateral external fixators at a single institution from 1999 through 2012. The patients' charts were analyzed for demographics, types of external fixators used, infection parameters, external fixator indexes, complications, positions of fusion, and leg length discrepancies (LLDs). Patients were called back to return for additional follow-up. A self-administered general health status questionnaire (SF-36) was assessed to evaluate life quality.There were 14 women and 3 men with an average age of 67 ± 16.6 years. Antibiotic-loaded acrylic cements were used as a spacer for an average of 3.4 ± 1.2 months in all patients. Monoplanar type of external fixator was used in all 17 patients. Fusions were achieved in all but one patient. The mean duration of fusion was 6.8 ± 2.2 months and external fixator duration was 7.6 ± 2.4 months. Average LLD was 2.9 ± 1.7 cm. The mean coronal alignment of fusion was 6.8 degrees (± 3.3 degrees, range 4-15 degrees) valgus and mean flexion was 11.3 degrees (± 6.5 degrees, range 3-30 degrees). Compared with the healthy controls, the SF-36 scores were significantly lower in patients with knee arthrodesis (physical component score [PCS]-arthrodesis: 39.3 vs. PCS- healthy controls: 47.9, p < 0.05; mental component score [MCS]-arthrodesis: 38.6 versus MCS-healthy controls: 47.7, p < 0.05).Use of monoplanar fixators for arthrodesis in infected TKA can achieve high fusion rates with the control of infection. If fusion can be achieved, the patient satisfaction is low with acceptable pain relief and functionality. We observed that monoplanar external fixators increased patients' comfort levels compared with circular external fixators. Further studies are needed to compare different arthrodesis modalities in patients with infected TKA.

Safety of posterior ankle arthroscopy portals in different ankle positions: a cadaveric study.

PURPOSE: To investigate anatomic relation of standard and coaxial ankle arthroscopy portals with neurovascular structures during different degrees of ankle motion. METHODS: Twenty posterior ankles of ten fresh cadavers were assessed. Posteromedial, posterolateral and coaxial (transmalleolar) portals were created using 4-mm Steinmann pins in accordance with the defined technique in neutral position. The ankles were then dissected, and the distance from the portals to the peroneal tendons, short saphenous vein and sural nerve was measured laterally and that from the tibial nerve, flexor hallucis longus tendon and posterior tibial artery was measured medially. Changes in the distance between these structures were noted in neutral positions, 15° of dorsiflexion and 30° plantar flexion. RESULTS: In the neutral position, the mean distance of the conventional posterolateral portal to the sural nerve was 6 mm (SD 2.9, range 2.7-14.5). The mean distance of the posterolateral coaxial portal to the peroneal tendon was 1.6 mm (SD 0.55, range 1.1-2.9). The mean distance of the posteromedial portal to the FHL was 2.11 mm (SD 1.1, range 0-4.7). The mean distance of the posteromedial coaxial portal to the posterior tibial artery was 6 mm (SD 1.4, range 3.9-9.5). Although not statistically significant, the distance between the portal and neurovascular structures increased in dorsiflexion for the portals placed posteriorly to the neurovascular structures and increased in plantar flexion for the portals placed anterior to the neurovascular structures. CONCLUSIONS: In comparison with the portals made in the neutral position, the distance between neurovascular structures and portals changes with portal placement in plantar flexion and dorsiflexion. In clinical practice, therefore, it might be safer to place the posteromedial-posterolateral portals in dorsiflexion and posterolateral-posteromedial coaxial portals in plantar flexion. The tibial nerve is closer to the posteromedial coaxial in dorsiflexion and could be in danger if making this portal with the foot in this position.

Hip fractures in patients older than 75 years old: Retrospective analysis for prognostic factors.

BACKGROUND: Proximal femoral fractures are often seen in older patients and are associated with high mortality. Introduction to old age population is latening due to advancements in medical sciences and increasing life expectancy. OBJECTIVES: The aim of the study was to evaluate factors affecting mortality in patients above 75 years of age who had been operated because of proximal femur fractures. PATIENTS AND METHODS: Patients with age 75 and over who suffers from post-fall proximal femoral fracture who underwent surgery with one of following three methods (hemiarthroplasty, proximal femoral nail or total hip arthroplasty) were evaluated retrospectively. Effects on mortality were examined for factors such as type of surgery, type of anesthesia, preoperative ASA score (American Society of Anesthesiologists Score), need for intensive care, need for blood transfusion, operation waiting time and hospitalization duration. 115 patients who met inclusion criterion were included in the study out of 224 overall. 75 patients were women and 40 were males. RESULTS: Mortality rate after first year was found to be 40%. Patients over 85 years old had higher rates of mortality (p = 0,0003) than respectively younger patients (75-85). Sex was found to have no impact on mortality (p = 0.5039). There was no statistically significant difference in terms ASA score (p = 0.1518). Order of applied surgical methods with mortality risk rates was found to be total hip arthroplasty > hemiarthroplasty > proximal femoral nail (p = 0.0003). Type of anesthesia, the use of cement during arthroplasty, operation waiting time and hospitalization duration was not directly related with mortality rate (type of anesthesia p = 0.63, the use of cement during arthroplasty p = 0.223, operation waiting time p = 0.5 and hospitalization duration p = 0.19). CONCLUSIONS: Age is the primary risk factor on first year mortality in patients older than 75 years old with hip fractures. Addition to older age, more need to blood transfusions, and arthroplasty are other risk factors for first year mortality. It should be kept in mind that after 75 years old first year mortality may be higher if the patient is treated with arthroplasty.