Comparison of new design locked intramedullary nails and plate osteosynthesis in adult isolated diaphyseal radius fractures.

PURPOSE: In this study, we retrospectively evaluated patients with isolated diaphyseal radius fractures treated with plates or IMNs and compared their radiological and functional results. METHODS: 49 patients who met the criteria were included in the study. Of these, 22 were treated with plate osteosynthesis and 27 with IMNs. The mean age of plate group was 36.8 (range 17-68), IMN group was 34.3 (range 18-74). 39 (79.6%) of the patients were males and 10 (20.4%) were females. The mean follow-up period was 26 (range 12-48) months. RESULTS: The mean union time was 12.1 ± 0.9 weeks in the IMN group and 12.2 ± 1.2 weeks in the plate group. Union was achieved in all patients in the IMN group (100%) and in 21 of 22 patients in the plate group (95.4%). The mean operation time was 21 (range 15-35) min in the IMN group and 46 (range 40-110) min in the plate group. There was no statistically significant difference between groups according to DASH scores, Grace-Eversmann evaluations, grip strength, forearm pronation and supination degrees, type of fracture, length of hospital stay, and time between injury and surgery (p > 0.05). Complete elbow and wrist range of motion was achieved in all patients. CONCLUSIONS: With similar union rates, functional results, and shorter operating times, locked IMNs are a suitable alternative to plate osteosynthesis in adult isolated diaphyseal radius fractures.

Treatment of adult isolated ulnar diaphyseal fractures: A comparison of new-generation locked intramedullary nail and plate fixation.

OBJECTIVES: This study aims to compare the radiological and functional results of adult patients with isolated ulnar diaphyseal fractures treated with plate and new-generation locked intramedullary nail (IMN). PATIENTS AND METHODS: The study included 57 patients (38 males, 19 females; mean age 39.1 years; range, 18 to 77 years) with isolated ulnar diaphyseal fractures treated with IMN or plate fixation between January 2008 and December 2017. Thirty patients (Plate group) were treated with plate fixation and 27 patients (IMN group) with IMN. Functional results were evaluated according to the Grace-Eversmann evaluation system and the disabilities of the arm, shoulder and hand (DASH) questionnaire. RESULTS: The mean union time was 12.8±1.2 weeks in the IMN group and 13.7±1.4 weeks in the plate group (p=0.092). The mean operation time was significantly shorter in the IMN group (30 minutes) than in the plate group (46 minutes; p<0.001). The mean DASH score was 7.0±4.5 in the IMN group and 7.7±8.6 in the plate group (p=0.766). CONCLUSION: With similar union rates, functional results, and shorter operation times, locked IMNs are a suitable alternative to plate osteosynthesis in adult isolated ulnar diaphyseal fractures.

A novel intramedullary nail for use in the treatment of supramalleolar malunion and nonunion: A preliminary report of three cases.

INTRODUCTION: The fractures around the supramalleolar region are difficult to manage and deformities may occur following insufficient or inadequate treatment attempts. The treatment of those deformities is even more challenging. The available options for surgical fixation have inherent problems considering the soft tissue problems, infection and compliance of the patients. In this study, we report the preliminary outcome of new IMN system in use of supramalleolar deformities. PATIENTS AND METHODS: Three patients with supramalleolar deformities were recruited for this study. Two patients had periarticular distal tibia malunions and one patient had nonunion in same region. All patients were operated with using newly designed intramedullary nail system with a unique distal interlocking bolt screw. The outcome for each patient was followed-up and evaluated with using AOFAS score. RESULTS: The patients were followed up for 3 years, 3 months, and 6 months, respectively. The AOFAS scores were 36, 33, and 21 preoperatively; and 75, 68, and 75 postoperatively in Patients 1, 2 and 3, respectively. CONCLUSION: In our patient series, adequate fixation following correction of the deformity was seen. Although the number of the cases are limited this study provides encouraging results regarding the outcome of new IMN system in use of supramalleolar deformities.

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.

Bilaterally Symmetrical Lower Extremity Compartment Syndrome following Massive Transfusion.

Compartment syndrome is a serious condition characterized by raised intracompartmental pressure, which develops following trauma. Well leg compartment syndrome (WLCS) is a term reserved for compartment syndrome in a nontraumatic setting, usually resulting from prolonged lithotomy position during surgery. In literature, 8 cases have been reported regarding well leg compartment syndrome in a supine position and bilateral symmetrical involvement was observed in only 2 cases. In WLCS etiology, lengthy surgery, lengthy hypotension, and extremity malpositioning have been held responsible but one of the factors with a role in the etiology may have been the tissue oedema and impaired microcirculation formed from the effect of vasoactive mediators expressed into the circulation associated with the massive blood transfusion. The case is presented here regarding symmetrical lower extremity compartment syndrome after surgery in which massive transfusion was made for gross haemorrhage from an abdominal injury. In conclusion, blood transfusion applied at the required time is life-saving but potential risks must always be considered.

Comparação entre fio de kirshner e hastes elásticas de titânio em fraturas pediátricas da diáfase femoral / Kirschner wire versus titanium elastic nails in pediatric femoral shaft fractures

Objetivo: Avaliar a eficácia da fixação intramedular usando o fio deKirschner em comparação com hastes elásticas de titânio (HET)nas fraturas pediátricas da diáfise do fêmur. Métodos: Pacientespediátricos com fraturas da diáfise femoral foram submetidos àfixação intramedular usando o fio de Kirschner ou HET em umgrupo de 42 crianças com idade média de 6,55±2,42 (4-11) anos.Resultados: Não houve diferença significativa entre os grupos,onde 16 (38,1%) pacientes foram tratados com fio de Kirschner e26 (61,9%) pacientes com HET em termos de duração de união.Ademais, nenhum dos pacientes demonstrou má união ou uniãoretardada. Conclusões: O uso do fio de Kirschner ajustado em vezde HET na fixação intramedular de fraturas diafisárias do fêmurem crianças selecionadas pode ser uma opção cirúrgica vantajosadevido ao menor custo, fácil acessibilidade e ausência da necessidadede uma segunda cirurgia para remoção do implante. Nívelde Evidência III, Estudo Retrospectivo.

Objective: To evaluate the effectiveness of intramedullary fixationusing the Kirschner-wire (K-wire) compared to the titaniumelastic nail (TEN) in pediatric femoral shaft fractures. Methods:A sample of 42 pediatric patients with a mean age of 6.55±2.42years (range 4-11 years) presenting femoral shaft fractures underwentintramedullary fixation using the K-wire or TEN. Results:There was no significant difference found between groups, ofwhich 16 (38.1%) patients were treated with K-wire and 26(61.9%) patients were treated with TEN in terms of union duration.Moreover, none of the patients showed nonunion or adelayed union. Conclusions: The use of adjusted K-wire insteadof TEN in the intramedullary fixation of femoral shaft fracturesin selected children may be an advantageous surgical optiondue to the lower cost, easy accessibility and no need for asecond surgery for implant removal. Level of Evidence III,Retrospective Study.

KIRSCHNER WIRE VERSUS TITANIUM ELASTIC NAILS IN PEDIATRIC FEMORAL SHAFT FRACTURES.

OBJECTIVE: To evaluate the effectiveness of intramedullary fixation using the Kirschner-wire (K-wire) compared to the titanium elastic nail (TEN) in pediatric femoral shaft fractures. METHODS: A sample of 42 pediatric patients with a mean age of 6.55±2.42 years (range 4-11 years) presenting femoral shaft fractures underwent intramedullary fixation using the K-wire or TEN. RESULTS: There was no significant difference found between groups, of which 16 (38.1%) patients were treated with K-wire and 26 (61.9%) patients were treated with TEN in terms of union duration. Moreover, none of the patients showed nonunion or a delayed union. CONCLUSIONS: The use of adjusted K-wire instead of TEN in the intramedullary fixation of femoral shaft fractures in selected children may be an advantageous surgical option due to the lower cost, easy accessibility and no need for a second surgery for implant removal. Level of Evidence III, Retrospective Study.

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.

Biomechanical comparison of antirotator compression hip screw and cannulated screw fixations in the femoral neck fractures.

OBJECTIVE: The aim of this study was to compare the biomechanical properties of minimal invasive sliding antirotator compressive hip screw (MIS-A-CHS), and multiple cannulated screws (CS) on a Pauwels type 3 femoral neck fracture model. METHODS: A Pauwels type 3 vertical femoral neck fractures was created on 12 third-generation proximal femur models which were divided into two equal groups. The fracture was fixed with three CS in the first group, and MIS-A-CHS in the second group. The axial and rotational stiffness and maximum compression effect were compared between the groups. RESULTS: The axial and rotational stiffness and maximum compression were significantly higher in MIS-A-CHS group (912.5 N, 540 N and 10.2 N/m, respectively) than the CS group (627.5 N, 380 N, and 3.9 N/m, respectively). CONCLUSION: MIS-A-CHS appears to be a more secure fixation method in Pauwels type 3 femoral neck fractures than the CS.

A comparison of epidural analgesia and local infiltration analgesia methods in pain control following total knee arthroplasty.

OBJECTIVE: The aim of this study was to compare the effects of epidural analgesia with infiltration analgesia in postoperative pain control for total knee arthroplasty. METHODS: Thirty patients (28 female, 2 male; mean age: 69.37±5.11 years, range: 61 to 80 years) undergoing total knee arthroplasty between May 2011 and September 2011 were randomly divided into 2 groups. All patients received spinal anesthesia with bupivacaine. Postoperative analgesia of 72 ml 0.9% NaCl + 48 ml bupivacaine (1 ml = 5 mg, total 120 ml) was administered throughout 24 hours to Group 1 (n=15) by epidural catheter and to Group 2 (n=15) by ON-Q infiltration pump. Groups were compared based on the Bromage scores and visual analog scale (VAS), blood pressure, postoperative analgesia requirement and side effects. RESULTS: Demographic data were similar in both groups. Rates of additional analgesia requirement at the postoperative 60th minute and 2nd hour were significantly higher in Group 2 than Group 1 (p<0.05). Rates of nausea-vomiting at the postoperative 60th minute and 2nd hour were significantly higher in Group 1 than Group 2 (p<0.05 and p<0.01, respectively). Bromage scores at 60 minutes and 2 hours was significantly higher in Group 1 than in Group 2 (p<0.01). Mean VAS scores at 60 minutes and 2 hours were significantly higher in Group 2 than Group 1 (p<0.05). While a statistically significant difference was found between systolic arterial pressure measurements at 60 minutes (p<0.05), there was no significant difference in diastolic arterial pressure and peak heart rate. CONCLUSION: Although the analgesic effect of local infiltration is provided later than by epidural analgesia, the same level of pain control can be achieved with initial additional analgesia. Local infiltration is superior to epidural analgesia in respect of few side effects and early mobilization.

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.

Medial humeral condyle fractures in adolescents: treatment and complications.

The very rare isolated medial humeral condyle fractures in children and adolescents pose significant problems to orthopedic surgeons such as ulnar nerve injury, trochlear irregularities, fishtail deformity and motion loss. Six adolescent boys with displaced medial humeral condyle fractures with an average age of 14.8 (range 12-17) were included in this study. Patients were followed-up with a mean of 39.8 months (range 21-72). In three patients, there were clinical signs of ulnar nerve dysfunction at initial presentation. Of these, two had only mild hypoesthesia on the ulnar side. The other patient had sensory and motor loss of ulnar nerve at initial presentation complicated by hypothenar atrophy and anhydrosis during follow-up. Complete recovery was seen in this patient only at 2 years. One patient without a neurologic compliant at initial presentation developed mild hypoesthesia on the ulnarly innervated areas postoperatively with complete resolution. Medial skin incision was used for open reduction and internal fixation. No signs of gross morphologic damage were seen on the nerve. The symptoms resolved postoperatively in 3 months time in three of the patients, but in the remaining one, it took 2 years for complete resolution of the symptoms. Also, trochlear irregularity and fishtail deformity were seen on radiographs of two different patients. In all but one patients, motion loss ranging from 10° to 20° was evident on physical examination. The most important finding of this study revealed that transient ulnar nerve dysfunction was seen two-thirds of the patients in this series than any other series reported previously. In three series, only one case of ulnar nerve injury was reported from a total of 19 patients. A possible explanation for such a difference may be the older age in this series.

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.

Interlocking intramedullary ulna nails in isolated ulna diaphyseal fractures: a retrospective study.

OBJECTIVE: The aim of this study was to evaluate the results of multifunctional intramedullary (IM) ulna nailing following diaphyseal fracture of the ulna. METHODS: Adult patients with isolated fractures of the ulna treated with closed or mini-open reduction using the new IM ulna nail between May 2008 and January 2011 and who were followed for a least one year were retrospectively reviewed. Patients with a pathological fracture or nonunion after previous surgeries were excluded. Functional outcome was assessed using the Grace and Eversmann rating system, patient-reported outcomes using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Wrist flexion and extension was evaluated using a goniometer. RESULTS: The 18 patients (13 male, 5 female; mean age: 28 years, range: 18 to 64 years) had a total of 20 isolated ulna fractures (two bilateral). Mean time to fracture union was 13 (range: 10 to 14) weeks. No patient had nonunion, deep infection or radioulnar synostosis. Follow-up time ranged from 12 to 36 months. Grace and Eversmann ratings were excellent in 15 patients, good in 2 and poor in one. Mean DASH score was 8.08 (range: 0 to 17.5) points. CONCLUSION: The new IM ulna nails may be considered an alternative method for isolated diaphyseal fractures of the ulna. Advantages of this method include its short operative time, insertion by closed and minimal invasive techniques, use of scope only in reduction and locking control, as well as minimal cosmetic defect, small operative scar and early mobilization without additional fixation.

Tips and tricks in the diagnostic workup and the removal of foreign bodies in extremities.

OBJECTIVE: The aim of this study was to analyze the diagnostic and therapeutic challenges during the removal of foreign bodies in extremities, and to provide relevant tips and tricks. METHODS: The medical records of 295 patients (150 men, 145 women; mean 26.82 ± 16.84 years; range: 3 to 79 years) who underwent foreign body removal from their limbs between February 2005 and July 2011, were retrospectively reviewed. Side of the extremity, foreign body type, location, complaints, imaging technique, the season of injury, the effects of foreign body in the body, the time between injury and extraction, indication for extraction, type of anesthesia, the use of fluoroscopy during the surgical procedure, and complications of surgical intervention were analyzed. RESULTS: The injury was in the right limb in 157 patients and in the left limb in 138 patients. Foreign bodies were in the elbow in 4 cases, in the forearm in 6, in the wrist in 6, in the hand in 75, in the hip in 1, in the thigh in 7, around the knee joint in 11, in the knee joint in 6, in the lower leg in 10, in the ankle in 8, and in the foot sole in 161. The season of injury was summer in 148 cases, winter in 107, spring in 35, and autumn in 5. The removed foreign bodies were needles in 216 cases, metallic objects in 33, pieces of glasses in 28, pieces of wood in 10, pieces of plastic in 4, and pieces of stone in 4. The time between the injury and foreign body removal was 1 day in 135 cases, 2 to 10 days in 114, 11 to 30 days in 22, and 30 to 365 days in 13. The removal time was longer than 1 year such in 11 cases. CONCLUSION: Foreign body injuries may result in serious complications such as infection, migration and joint stiffness. A throughout history and physical and radiological examinations are of tremendous importance to achieve the best outcome in these patients.