Free vascularized fibular grafts in Type 3 open tibia fractures.

OBJECTIVE: The aim of this study was to evaluate the results and complications of free vascularized fibular grafting (FVFG) for the reconstruction of bone defects in Gustilo Type 3 open tibia fractures. METHODS: Free vascularized fibular grafting was performed on open tibia fractures with a bone defect of an average of 10 (range: 6 to 18) cm in 21 patients (19 males, 2 females; mean age: 32 years; range: 16 to 47 years). Primary FVFG was performed for 15 patients with open fractures and secondary FVFG in 6 patients with osteomyelitis due to open fractures or defective nonunions. Bony unions were evaluated retrospectively. At a mean follow-up time of 74 (range: 18 to 216) months, 18 patients were examined for malalignment, shortness, and range of motion. Quality of life was evaluated using the Short Form 36 (SF-36). RESULTS: Mean bony union times for the proximal and distal fibula were 19 (range: 16 to 24) weeks and 20 (range: 16 to 28) weeks, respectively. Proximal nonunion was detected in three patients. Mean external fixation removal time was 6.3 (range: 3 to 14) months. Stress fractures occurred in 15 patients following fixator removal. Malalignment of over 5 degrees was detected in 7 patients and shortness over 2 cm was detected in 4 patients. SF-36 scores were significantly lower in the domains of physical functioning, role limitation due to physical problems, bodily pain, general perception of health, social function, and role limitation due to emotional problems. Mental health, energy and vitality were similar to the healthy reference group. CONCLUSION: Free vascularized fibular grafting appears to be a reliable and effective method for reconstructing bone defects and soft tissue defects in a single session in open tibia fractures.

Peroneal nerve injury surgical treatment results.

OBJECTIVE: The purpose of this study was to retrospectively evaluate the clinical and functional results of nerve grafting and end-to-end peroneal nerve repair between sciatic bifurcation and distal branching. METHODS: The study included 26 patients (22 men, 4 women; mean age: 19.9 years; range: 5 to 46 years) who underwent peroneal nerve repair between 1992 and 2009. Open nerve injuries were seen in 21 patients and closed injuries in 5. Surgical repair was performed with sural nerve grafting in 19 patients and end-to-end in 7. Mean nerve graft length was 5.42 (range: 2 to 15) cm with a mean 3.1 (range: 2 to 4) nerve cables used. Mean follow-up was 33 (range: 13 to 96) months. The British Medical Research Council (BMRC) scale was used for the evaluation of the tibialis anterior and peroneal muscles and Semmes-Weinstein monofilaments were used for protective sensation evaluation. RESULTS: Adequate and full recovery was observed in 19 patients (73%). Mean follow-up time was 39.3 months in patients undergoing nerve grafting and 30.1 months in end-to-end nerve repair. Fifteen of 19 patients with nerve grafting and 4 of 7 patients with end-to-end nerve repair had an adequate or full recovery. Posterior tibial tendon transfer to dorsal foot was applied in 3 of 7 patients without recovery. Protective sensory recovery was determined in 16 of 22 patients. CONCLUSION: Good results in both end-to-end repair and in repair with grafting is possible in peroneal nerve repair.

Long-term functional results after radial nerve repair.

OBJECTIVE: This study aimed to evaluate the functional results of end-to-end repairs in radial nerve injuries. METHODS: The study included 18 (15 males, 3 females) patients who underwent middle level end-to-end radial nerve repair and who responded to our final follow-up call. Patients' average age was 30 (range: 16 to 43) years. The average time lapse between injury and repair was 25.1 days (range: 1 day to 13 months). Pinch and grip strength measurements were graded according to the modified Verga classification. The Highet classification was used for the evaluation of sensorial recovery. Functional outcome were assessed with the DASH-T score. Average follow-up time was 62.5 (range: 24 to 156) months. RESULTS: Motor function according to the Verga classification was excellent in 16 patients and poor in two. Pinch and grip power measurement comparison of the two sides in the 16 patients with excellent results showed a respective 24.1% and 14.3% decrease on the affected side. According to Highet's classification, sensorial evaluation was S4 in seven patients, S3+ in four, S3 in three, S2+ in one, S2 in one, and S1 in two patients. The average DASH-T score of patients with excellent results was 7.3. CONCLUSION: Radial nerve repairs, if done end-to-end using an appropriate technique, may lead to nearly full recovery in younger patients.

The effect of excisional arthroplasty with palmaris longus tendon on carpal height ratio in Stage 3 Kienböck's disease.

OBJECTIVE: Treatment methods in Kienböck's disease remain controversial despite the long-term awareness of the disease by orthopedic surgeons. Currently, excisional arthroplasty with a palmaris longus tendon ball is one of the most frequently used treatment methods. The aim of this study was to evaluate the long-term results of thirty-eight patients who had been treated with excisional arthroplasty and palmaris longus tendon ball, as well as the effect of this method on carpal height. METHODS: In this study, we retrospectively evaluated 38 patients (mean age: 30.4 years; range: 17-64 years) with Stage 3 Kienböck's disease who underwent excisional arthroplasty between 1978 and 2008. According to the Lichtman classification, 8 patients were classified as Stage 3a and 30 patients were classified as Stage 3b in Kienböck's disease. The mean duration of follow-up after surgery was 81.3 (range: 25 to 264) months. The outcomes were evaluated with joint range of motion, grip strength and functional assessment of Nakamura and radiographic changes in carpal height. RESULTS: According to the Nakamura's scoring system the results were excellent in 22 (57.9%) patients, good in 13 (34.2%) and moderate in 3 (7.9%). Comparison of pre and postoperative range of motion of the wrist revealed an average increase in wrist extension of 10° (p<0.05), and an average decrease in ulnar deviation of 4° (p<0.05) after the operation. No significant difference was observed when comparing other joint range of motion parameters. Dynamometric grip strength measurements revealed significant differences between the healthy and operated sides (67.6 kgf vs. 45.9 kgf, respectively; p<0.05). The decrease in the revised carpal height ratio were significant. CONCLUSION: According to patient satisfaction rate and clinical results, the outcome of excisional arthroplasty with palmaris longus tendon ball in Stage 3 Kienböck's disease is satisfactory. However, carpal height reduction and development of degenerative changes may be expected in long-term follow-up.

Stiffness after total knee arthroplasty: prevalence, management and outcomes.

We investigated the prevalence of stiffness after total knee arthroplasty, and the results of the treatment options in our practice. Between 1987 and 2003, we performed 1188 posterior-stabilized total knee arthroplasties. The prevalence of stiffness was 5.3%, at a mean follow-up 31 months postoperatively. The average age was 71 years (range, 54-88). The patients with painful stiffness were treated by two modalities: manipulation and secondary surgery. In the manipulation group (n:46), the mean range of motion improved from 67 degrees before manipulation to 117 degrees afterward. This improvement was maintained at final follow-up as 114 degrees. There was no significant difference between the motion, immediately after manipulation and at final follow-up. However, motion at final follow-up was better for those manipulated early to those done later (p=0.021). In the secondary surgery group (n:10), the mean gain in motion was 49 degrees at final follow-up and average pain score was found 43. Patellar problems--component loosening and clunk syndromes--were found in 4 patients (40%). Early manipulation gives better gain of motion than done later and our patients had not lost flexion during follow-up. The patella should always be evaluated in every stiff arthroplasty. In our opinion, patellar problems are a good prognostic factor for the success of revision surgery and open arthrolysis does not correct a limited flexion arc, but it does relieve pain. Arthroscopic release is not reliable for severely stiff knees and we prefer to perform it in less painful and moderately stiff knees within 3 to 6 months after operation.

Tibiofemoral instability in primary total knee replacement: a review, Part 1: Basic principles and classification.

Tibiofemoral instability following total knee replacement has received little attention. However it is a cause of early and late failure and usually requires revision surgery. Several factors may be implicated including improper soft tissue balancing, flexion-extension gap mismatch and acute ligamentous injuries. Meticulous surgical technique and proper prosthetic selection at the primary procedure avoids this complication.