Does an infra pectineal plate alone provide adequate fixation in anterior column posterior hemitransverse acetabular fractures? A comparative biomechanical study.

BACKGROUND: The purpose of this study is to compare biomechanical properties of suprapectineal (SP) plate fixation, in-frapectineal (IP) plate fixation, and both SP and IP plate fixation in anterior column posterior hemitransverse (ACPHT) fractures of the acetabulum using posterior and anterior column screws. METHODS: In 21 hard plastic left hemipelvis models, ACPHT fractures of the acetabulum were created, and in three different fixa-tion groups, the methods were compared: Group 1: SP plating using a 3.5 mm reconstruction plate and cortical screw fixation, Group 2: Infrapectineal plating using 3.5 mm reconstruction plate and cortical screws combined with posterior and anterior column screws, and Group 3: Combined fixation with SP and IP plating using 3.5 mm reconstruction plates and cortical screws. Maximum load to failure (strength) of these three groups was compared between groups. RESULTS: The mean maximum load of failure for three groups was 2921 N, 2018 N, and 3658 N, respectively. When strength was compared considering the force that causing implant failure, it was determined that the strongest fixation was achieved when SP and IP fixation method were applied together, followed by SP only fixation and IP fixation supported by anterior and posterior column screws, respectively. CONCLUSION: The combined application of SP and IP fixation provides the most stable fixation of the ACPHT acetabular frac-tures, and IP fixation does not provide comparable biomechanical stability despite reinforcement with three-column screws placed away from the plate. Although IP fixation supported by anterior and posterior column screws with the limited combined approach is less invasive approach for patients, SP fixation should be included in the surgical treatment method to ensure adequate stability.

Is simple decompression enough for the treatment of idiopathic cubital tunnel syndrome: A prospective comparative study analyzing the outcomes of simple decompression versus partial medial epicondylectomy.

OBJECTIVES: This study aims to compare the clinical and functional outcomes of simple in-situ decompression and partial medial epicondylectomy for the treatment of idiopathic cubital tunnel syndrome (CuTS). PATIENTS AND METHODS: Between March 2014 and December 2016, 71 patients (31 males, 40 females; mean age 46.7 years; range, 38 to 62 years) with CuTS scheduled to undergo simple in-situ decompression (group 1) or partial medial epicondylectomy (group 2) were prospectively reviewed. All patients were analyzed with clinical examination (Tinel sign, Froment's and Wartenberg's signs, elbow flexion test, subluxation), and McGowan scores before and after surgery. Final outcomes were reviewed with Wilson and Krout grading system. RESULTS: There was no significant difference between the study groups in regard to Wilson and Krout grading and McGowan scores postoperatively. Group 1 had significantly better grip and key pinch strength values compared to group 2 at the final follow-up control. CONCLUSION: In-situ decompression and partial medial epicondylectomy represent efficient and safe methods for the treatment of idiopathic CuTS. When their efficiency is compared, in-situ decompression had better grip and key pinch strength values and more excellent outcomes compared to partial medial epicondylectomy.

Internal fixation of bilateral sacroiliac dislocation with transiliac locked plate: a biomechanical study on pelvic models.

OBJECTIVE: The purpose of this study was to analyze and compare the mechanical characteristics of a new iliosacral fixation technique (bilateral S1 pedicle fixation through a transiliac locked plate) for bilateral sacroiliac dislocations with other previously described methods. METHODS: Bilateral sacroiliac dislocations were created in 21 pelvic models and divided into three different fixation method groups. Group 1 was fixed using posterior tension band plating with a 3.5 mm locked plate combined with fixed-angle locked 3.5 mm screw fixation of bilateral S1 vertebra pedicles through suitable holes of the plate. Group 2 underwent posterior tension band plating with a 3.5 mm locked plate combined with bilateral spongious iliosacral screw fixation and Group 3 bilateral iliosacral spongious screw fixation alone. The ultimate load to failure and load for 10 mm of displacement for all three groups were compared. RESULTS: The average loads to failure for Groups 1, 2 and 3 were 1775, 2084 and 2230 N, respectively, and average loads for 10 mm of displacement were 1033, 1884 and 2013 N, respectively. Group 2 and 3 had the strongest fixation constructs although there was no statistically significant difference between these two groups (p=0.452). Group 2 and 3 were superior to Group 1 in terms of loads for 10 mm of displacement. There was no significant difference between Group 2 and 3 in this regard (p=0.397). CONCLUSION: Iliosacral screws are superior to bilateral S1 pedicle fixation through posterior tension band plating. However, the combination of tension band plating with iliosacral screw fixation does not improve the stability of the posterior pelvic ring.

A lipoma causing separation of toes in the second web space of the foot.

Lipomas are common and benign soft tissue neoplasms which are composed of fat cells. These tumors often develop where adipose tissue is present; however, they can be rarely found in the foot. In this article, we present a 55-year-old male case with a lipoma leading to separating toes in the second web space of the foot and mechanical discomfort.

Primary extracranial meningioma of the lower limb.

This paper is about a primary extracranial meningioma case of a 40-year-old male patient who presented with a complaint of a rapidly growing painless stiff mass located in his left thigh. The magnetic resonance imaging examination revealed that the lesion was well-circumscribed and with isosignal intensity to muscle on T1-weighted images and with a relatively hiperintense on T2-weighted images. The histopathological analysis of the specimens both from the incisional biopsy and the excisional surgery were typical of meningioma showing spindle cell proliferation with a whirling pattern. Although extracranial meningiomas are very rare, it should be considered in the differential diagnosis of a spindle cell neoplasm.

Prevention of web creep using a new frame after synpolydactyly surgery.

The main goal in syndactyly surgery is to create a normal web space; however, it is difficult to achieve the best clinical results in older and complex cases with bony fusions and joint deformities requiring osteotomies. In these complex cases, proper postoperative wound care is difficult to achieve due to the web contractures and deformities. In our report, we introduce a new technique using a frame that we called the "Hittite Sun," which helps in proper wound management to reduce wound healing problems that lead to web creep. Between 2002 and 2006, this frame was used in operations for 46 webs, and the results were compared with those of 30 operated webs in which conventional wound management technique was used. It was found that significantly lower complication rate and lesser web creep formation was seen in these patients, which were managed using the frame, compared with the cases with conventional wound care. The frame was found to be effective for prevention of severe web creep especially in complex synpolydactyly surgery.

Biomechanical comparison of conventional technique versus oblique screw placement in plate fixation.

BACKGROUND: The aim of this study was to evaluate whether plate fixation with screws in an oblique fashion would change the strength of the fixation to bending forces and whether any relationship existed between deformity and increased strength of fixation. METHODS: Rear leg tibias from 2-year to 3-year-old sheep were affixed with the help of a custom-made guide to a six-hole dynamic compression plate and divided into three groups. In group 1, fixation was performed using screws perpendicular to the plate axis in two planes. In group 2, screws were placed at a 20-degree angle to the axis of the shaft and perpendicular to the transverse plane. In group 3, the screws were placed at a 20-degree angle to the shaft axis and 7 degrees on the transverse plane. Gap-close bending and side-bending tests were performed in a three-point bending fashion. The maximum moment of force and deformation at the time of the failure was analyzed. RESULTS: In gap-close bending tests, mean maximum moment of forces for groups 1, 2, and 3 was 51.90 Nm, 67.47 Nm, 82.05 Nm, respectively (p<0.05 for group 1 vs. groups 2 and 3; p=0.053 for group 2 vs. group 3). In side-bending tests, the mean maximum moment of force was 34.63 Nm, 49.91 Nm, and 49.29 Nm, respectively (p<0.05 for group 1 vs. groups 2 and 3; no significant difference was observed between groups 2 and 3). When the two bending tests were evaluated together, only the mean moment of forces of groups 1 and 3 were statistically different (p=0.006). There was no difference between any groups in terms of the deformity at the time of the maximum moment of force. CONCLUSION: Oblique screw placement in two planes increases the strength of the plate-screw fixation under bending forces; however, there is no relationship between deformity and increased strength of fixation.

[The effect of periosteum on the union of the autoclaved bone graft-host bone: experimental study in rabbits]. / Periost dokusunun otoklavize kemik grefti-alici kemik bütünlesmesine etkisi: Tavsanlarda deneysel çalisma.

OBJECTIVES: In this study, we investigated the effect of periosteum on the union of autoclaved segmental bone grafts harvested from rabbit radii and replanted to their beds with intramedullary fixation to host bone. MATERIALS AND METHODS: Segmental bone defects, 15 milimeters long, in the middle of the left radius were created in 16 adult rabbits. The resected bones were autoclaved 15 minutes at 120 °C and reimplanted and fixed with intramedullary Kirschner wires. The rats were divided into two groups; in the first group, eight rabbits' graft-host bone junctions were covered with periosteal flaps and in the second group, graft-host bone junctions were deperiostized. Plain X-rays were taken at 2, 4, 6 and 8 weeks after the operation. At the end of the 8(th) week radiological results were evaluated with modified Yang's radiological scoring system. RESULTS: Radiological results revealed more callus tissue and early, better healing in the first group (mean 10.94), than in the second group (mean 6.06) at 8(th) week. The difference was statistically significant (p=0.04, <0.05). CONCLUSION: Periosteal flaps are biologic tissues that can be easily performed and enhance the healing of graft-host junctions. The periosteal flap technique is effective on the healing of graft-host bone junctions and this technique is worth applying to structural allografts.

Correlations of isokinetic measurements with tendon healing following open repair of rotator cuff tears.

The aim of this study was to investigate the correlation of tendon integrity following open cuff repairs with functional and isokinetic strength measurements. Twenty-six shoulders of 25 patients were included in this study. At the final follow-up, 14 repairs (53.8%) were intact and 12 repairs (46.2%) had failed on magnetic resonance imaging (MRI). Mean UCLA score at latest follow-up was 28.5 and mean Constant score was 80.3. Constant scores were found to be significantly low for the failed group. Age was found to be significantly related to failed repair. Fatty infiltration stage in the failed repair group was significantly high, and a strong positive correlation for both groups existed pre and postoperatively. When both groups were compared, the failed group was found to have significantly low measurements at extension and internal rotation. Despite high failure rates, functional results were satisfactory. Increased age and fatty infiltration stage decrease success.

[Early results of treatment of proximal humerus fractures with the PHILOS locking plate]. / Proksimal humerus kiriklarin PHILOS plagi ile tedavisinde erken dönem sonuçlarimiz.

OBJECTIVES: The aim of this study was to evaluate early results of proximal humerus fractures treated with the PHILOS locking plate. METHODS: Proximal humerus fractures of 22 patients (13 males, 9 females; mean age 57 years; range 35 to 83 years) were treated with the PHILOS locking plate. According to the Neer classification, 13 patients had comminuted fractures, four patients had valgus impact injuries, two patients had fracture-dislocations, and three patients had fractures involving the proximal 1/3 of the humerus. The fractures were reduced by the transdeltoid lateral approach (n=8) using minimally invasive surgery, and by the anterior deltopectoral approach (n=14) using open surgery. Passive and active exercises were initiated on the second postoperative day and after 4 to 6 weeks, respectively. The results were assessed using the Constant-Murley shoulder scoring system. The mean follow up was 14 months (range 12 to 19 months). RESULTS: Radiographically, union was observed in 20 patients at the end of 10 weeks. In one patient, time to union was 16 weeks. One patient underwent autogenous bone grafting because of nonunion after 16 weeks. The mean Constant-Murley score was 75.5 (range 51 to 93). There was no significant difference between Constant-Murley scores of patients undergoing the transdeltoid lateral and anterior deltopectoral approaches (p>0.05). Plate fixation was associated with minimal varus deformity in two patients, and subacromial impingement in one patient. Implant failure did not occur. Reflex sympathetic dystrophy and avascular necrosis were observed in two patients, respectively. CONCLUSION: Fixation with the PHILOS plate is a near-ideal technique with a high union rate in the treatment of proximal humeral fractures.

Analysis of modified oblique Keller procedure for severe hallux rigidus.

BACKGROUND: Several procedures have been described for treating hallux rigidus, but all have limitations. The purpose of this study is to evaluate the clinical and radiologic results of a modified oblique Keller procedure for treating hallux rigidus. MATERIALS AND METHODS: Eleven patients (13 feet) with Grade III or IV hallux rigidus were treated by modified oblique Keller procedure. Average age was 64.7 years and followup was 27.2 months. Outcomes including range of motion (ROM) of first metatarsophalengeal joint, complications, American Orthopaedic Foot and Ankle Society (AOFAS) scores, satisfaction, osteophyte recurrence, osteonecrosis, and shortening were analyzed. Preoperative and postoperative values were statistically compared. RESULTS: Mean preoperative and postoperative ROMs were 6.5 degrees and 51.9 degrees, respectively (p < 0.005). Two feet had numbness on the dorsum of the first toe. Transfer metatarsalgia occurred in one patient. Mean preoperative and postoperative AOFAS scores were 29.1 points and 93.6 points, respectively (p < 0.005). All patients had good or excellent results. There was no recurrence of the dorsal osteophyte. One patient had radiographic mottling of the first metatarsal head. Average preoperative and postoperative first toe length was 124.3 mm and 123.1 mm, respectively. CONCLUSION: This technique was a good treatment alternative for patients with end-stage hallux rigidus. It was a safe and reliable procedure that preserved range of motion and has good outcomes.

Analysis of outcomes for surgically treated hip fractures in patients undergoing chronic hemodialysis.

BACKGROUND: Hip fractures in patients with end-stage renal disease are associated with frequent complications. This study analyzed clinical outcomes for patients on chronic hemodialysis who sustained hip fractures and were treated with a variety of fracture repair methods. METHODS: Twenty-nine patients with thirty-two hip fractures were analyzed in three groups. Group 1 consisted of eleven hips in eleven patients with an intertrochanteric fracture that was treated with internal fixation; Group 2, thirteen hips in ten patients with a femoral neck fracture that was treated with screw fixation; and Group 3, eight hips in eight patients with a femoral neck fracture that was treated with hemiarthroplasty. The outcomes and early and late complications were recorded for each group. Survivorship analysis was performed, and the mortality and complication rates for the groups were compared. RESULTS: In Group 1, eight complications occurred in six hips and nonunion developed in five hips. In Group 2, sixteen complications developed in eleven hips. Union was achieved in two of the thirteen hips, nine hips had nonunion, and two hips had osteonecrosis develop. In Group 3, only one hip had early complications, there were no late complications, and three patients died. The mean duration of follow-up was twenty-three months, and the overall mortality rate was 45%. There were no significant differences among the groups with respect to the cumulative survival proportions. Regression analysis of age, sex, and total hemodialysis duration in relation to mortality risk revealed that only age had a significant influence on mortality (p = 0.019). CONCLUSIONS: Surgical treatment of hip fractures in patients with end-stage renal disease who are on chronic hemodialysis is associated with frequent complications and a high mortality rate. Osteosynthesis is an acceptable option for treating intertrochanteric fractures and nondisplaced femoral neck fractures, but displaced femoral neck fractures should be treated with hemiarthroplasty.

[Symptomatic lumbar intraspinal synovial cyst: a case report]. / Semptomatik lomber intraspinal sinovyal kist: Olgu sunumu.

Synovial and ganglion cysts, also known as juxta-facet cysts, are intraspinal lesions that may mimic disc herniations and cause radicular symptoms. A 75-year-old male patient presented with a 6-month history of left leg pain and numbness in the foot that increased in severity within the past week. Physical examination showed motor deficit of the left extensor hallucis longus muscle (4/5) and hypoesthesia on the left L4-5 dermatomes. Magnetic resonance imaging revealed an intraspinal cyst originating from the L4-5 facet joint. Medial facetectomy and cyst excision were performed, which provided immediate relief of pain. He had no loss of strength of the extensor hallucis longus muscle and his neurologic examination was normal during the first postoperative year.

Remote cerebellar hemorrhage after a spinal surgery complicated by dural tear: case report and literature review.

OBJECTIVE AND IMPORTANCE: This report presents a case in which cerebellar hemorrhage occurred after lumbar decompression surgery that was complicated by dural tear and prolonged cerebrospinal fluid leakage. Remote cerebellar hemorrhage after spinal surgery is extremely rare. Our objective is to describe this unusual complication, discuss the possible mechanisms of remote cerebellar hemorrhage, and review the literature. CLINICAL PRESENTATION: A 73-year-old woman underwent surgery for lumbar spinal stenosis. A dural tear occurred during decompression, and the patient developed remote cerebellar hemorrhage on postoperative Day 2. INTERVENTION: The cerebellar hemorrhage was treated surgically, and a biopsy of hemorrhagic brain parenchyma revealed an arteriovenous malformation. CONCLUSION: Although it is an extremely rare complication, remote cerebellar hemorrhage should be kept in mind as a possible complication of spinal surgery, especially in operations complicated by dural tears.

Pedunculated synovium grafts in articular cartilage defects in rabbits.

A rabbit model was used to assess the nature of healing tissues in hyaline cartilage defects and to compare the healing in defects treated with pedunculated synovium grafts to those in defects without synovial grafting. Both knees of 28 1-year-old rabbits were operated. A 3 x 2-mm cartilage defect that exposed cancellous bone was created in the non-weight-bearing area of each medial femoral condyle. Each right-knee defect was covered with a pedunculated synovial graft obtained from the same joint, and the left-knee defects were left uncovered as controls. Groups of rabbits were sacrificed at 3, 6, 12, and 24 weeks postsurgery. Sections from each knee were stained with hematoxylin-eosin and safranin O-fast green staining, and were immunohistochemically stained for type II collagen. The healing at each site was histologically scored, and the intensity of staining for type II collagen was graded. At 12 and 24 weeks, statistical comparisons of histological scores revealed significantly more hyaline cartilage tissue in the synovium-grafted defects. At 24 weeks, these same defects showed significantly more type II collagen. Thus, pedunculated synovium transplantation appears to hold promise as a method for repairing hyaline cartilage defects.

Is prematurity important in ultrasonographic hip typing?

The aim of this study was to determine whether prematurity is important with respect to hip typing and planning of treatment/follow-up in newborns assessed with the Graf's ultrasonography method. Between January 1998 and 2003, 1592 neonates; preterm (n=432) and term (n=1160), had their hips ultrasonographically evaluated with Graf typing. There were no statistical differences between the two groups with respect to the numbers of hips that required follow-up assessment, or treatment. The results suggest that prematurity is irrelevant and use of chronological age as opposed to corrected age for prematurity will further simplify diagnosis and planning of follow-up and treatment in the Graf system for neonatal hip assessment.

Multilevel vertebral hemangiomas: two episodes of spinal cord compression at separate levels 10 years apart.

This case report presents a 66-year-old woman with multiple vertebral hemangiomas causing spinal cord compression at different levels with a long symptom-free interval between episodes of compression. She presented with back pain and progressive weakness and numbness in her lower limbs for 3 months. Ten years earlier, she had had a symptomatic T4 vertebral hemangioma operated successfully, and had made a full recovery. Magnetic resonance imaging (MRI) of the thoracic and lumbar spine revealed multiple thoracic and lumbar vertebral hemangiomas. Extraosseous extension of a hemangioma at T9 was causing spinal cord compression. Selective embolization was performed preoperatively, and cord decompression was achieved via anterior T9 corpectomy. The patient's neurological status improved rapidly after surgery. After a course of radiotherapy, she was neurologically intact and could walk independently. One year later, MRI showed complete resolution of the cord edema at T9, and showed regression of the high signal intensity that had been observed at unoperated levels. These findings indicated diminished vascularity and reduced aggression of the tumor.

[Transforaminal epidural steroid injection under computed tomography guidance in relieving lumbosacral radicular pain]. / Lumbosakral radiküler agri tedavisinde bilgisayarli tomografi esliginde transforaminal epidural steroid enjeksiyonu.

OBJECTIVES: We analyzed the efficacy of transforaminal epidural steroid injections under computed tomography (CT) in relieving lumbosacral radicular pain due to spinal stenosis. METHODS: Forty-two patients (7 males, 35 females; mean age 67 years; range 34 to 90 years) with lumbosacral radicular pain due to spinal stenosis were prospectively monitored following transforaminal epidural steroid injections under computed tomography. Injections were repeated twice in two patients (4.8%) and three times in one patient (2.4%). The severity of pain was assessed with the use of a visual analog scale (VAS) before and after injections (1st day, 1st week, 3rd week, 6th month, and the last follow-up). The mean follow-up period was 12.1 months (range 6 to 25 months). RESULTS: The median VAS score before injections was 9 (range 6 to 10). During the first six months, the median VAS scores were always significantly lower than the preinjection score (p<0.005). The mean VAS score of 23 patients with a follow-up of at least a year was still significantly lower than that obtained at the end of six months (2.26 vs 2.52, p<0.005). No procedure-related complications occurred. CONCLUSION: Selective transforaminal epidural steroid and analgesic injection under CT guidance is a safe and reliable conservative method to relieve lumbosacral radicular pain due to spinal stenosis.

Synovial cysts of proximal tibiofibular joint causing peroneal nerve palsy: report of three cases and review of the literature.

INTRODUCTION: Synovial cyst of the proximal tibiofibular joint is a very rare condition, for which there is no consensus regarding treatment. CASE PRESENTATION: We present three patients who had synovial cysts of proximal tibiofibular joint that caused peroneal nerve palsy. We discuss the special features of synovial cysts and review the literature. CONCLUSION: We consider the best treatment of synovial cysts originating from proximal tibiofibular joint and causing peroneal nerve palsy to be total surgical removal as soon as possible after the diagnosis is made. It should be kept in mind that despite surgical treatment the neurological symptoms may not recover.

Avascular necrosis and nonunion after osteosynthesis of femoral neck fractures: effect of fracture displacement and time to surgery.

This study assessed the effect of fracture displacement and elapsed time before surgery on the development of avascular necrosis and nonunion after internal fixation of femoral neck fractures. Twenty-eight patients with 30 femoral neck fractures who underwent internal fixation and completed a minimum of 2 years' follow-up were retrospectively analyzed. The rates of avascular necrosis and nonunion were 12.5% and 25%, respectively, among patients who underwent surgery before 12 hours had elapsed and 14% and 27% among those who underwent surgery after that time. The rates of avascular necrosis and nonunion associated with fracture displacement were 6% and 18%, respectively, among patients with undisplaced (Garden stages 1 and 2) fractures and 23% and 38% among those with displaced (Garden stages 3 and 4) fractures. Nonunion and avascular necrosis led to the necessity for additional surgery in 11 of 30 (36%) hips. Internal fixation of femoral neck fractures is associated with a high initial complication rate, but if successful, the procedure ensures an excellent long-term outcome. Internal fixation should be considered the treatment of choice in young patients with nondisplaced fractures.