Greater tuberosity medial malposition: does it affect shoulder abductor moment?

PURPOSE: The detrimental effect of greater tuberosity malposition on functional scores is well known. Superior or posterior malpositions exceeding five mm lead to excessive loading on the deltoid strength. However, the significance of situations where greater tuberosity becomes medialized due to the compressive effect of the locking plate fixation, especially in fractures with metaphyseal dead space, has not been emphasized. It is hypothesized that this condition may cause shortening of the rotator cuff moment arm and consequently impact functional scores. METHODS: Between 2012 and 2018, 52 patients, aged 65,28 (ranging 40-85) proximal humerus fractures treated with locking plate fixation were included in the study. Cephalodiaphyseal angle, greater tuberosity displacement , patients reported outcome and Constant-Murley scores were evaluated. RESULTS: The mean Constant Murley score was determined to be 78.76 (ranging from 38 to 100). According to the patients reported outcome 39 excellent , five good , two fair, six poor results were observed. Avascular necrosis with screw migration was detected in five cases, while one patient experienced implant insufficiency along with varus deformity. Greater tuberosity was found to be positioned between 6 mm posterior-superior and -13 mm medial. Significant medial malposition was observed in three patients, with -9, -12, and -13 mm of medialization, respectively. Cephalodiaphysial angle was determined as 139.30 degrees (ranging from 120 to 150 degrees) and showed weak correlation with the functional score. Greater tuberosity medialization also showed weak correlation with the Constant-Murley score. The values exhibiting deviation were associated with low patient-reported outcome results and functional scores. In the examination of greater tuberosity displacement values, it was observed that Neer type 3 and 4 fractures differed significantly from Neer type 2 fractures regarding to Kruskal-Wallis test. CONCLUSIONS: Medial impaction of greater tuberosity may be the reason of decreased functional scores, similar to superior or posterior malposition. The medialization of greater tuberosity should be considered as a potential factor leading to the shortening of the rotator cuff's abductor moment.

Midterm results of intra-articular stromal vascular fraction injection for the treatment of knee osteoarthritis.

PURPOSE: This study aimed to evaluate the safety and efficacy of intra-knee stromal vascular fraction (SVF) injection in patients with symptomatic knee osteoarthritis at the midterm (3-year) follow-up. METHODS: SVF injection was applied to 25 knees of 20 patients. Eighteen patients (90%) were female, and the means ± standard deviations of age was 61.9 ± 7.8 (range, 50-76) years. Patients who received conservative treatment for at least 6 months and had radiographic Kellgren-Lawrence (K-L) grades 2 and 3 varus gonarthrosis were included in the study. SVF was obtained from the umbilical region by liposuction using local anaesthesia. Patients were followed-up for 36 months. Their visual analogue scale (VAS), Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and Lysholm scores were evaluated before and at 6, 12, 24 and 36 months post-SVF injection. RESULTS: A statistically significant improvement (p < 0.05) was observed in VAS, WOMAC and Lysholm scores at the first 2-year follow-up compared to baseline. However, no statistically significant difference (n.s.) was observed in VAS, WOMAC and Lysholm scores at the 3-year follow-up compared with baseline. CONCLUSION: Intra-articular SVF injection decreased pain and significantly improved the functional outcomes in the first 2 years in knees with grade 2-3 osteoarthritis; however, these positive effects of the injection disappeared in the 3rd year. Although short-term successful results of SVF have been reported in the literature, prospective studies are needed for medium- and long-term results.

Subgroups and differences of fixation in 3-part proximal humerus fractures.

BACKGROUND: This study aimed to determine the morphological differences of three-part proximal humerus fractures, the group in which plate screw fixation is most frequently used, and to evaluate the functional and radiological results of the methods applied for different subgroups. METHODS: Twenty-nine patients (6 males and 23 females) with three-part proximal humerus fractures were in the study, with an average age of 64. The patients were in three groups according to their fracture types. Group 1 included eight patients with valgus impaction fracture. Group 2 included eleven patients with easily achieved stability after reduction. Group 3 consisted of ten patients with procurvatum varus angulation, a significant displacement between fragments, and in whom medial cortical continuity was not maintained without fixation. All patients underwent surgery with a minimally invasive deltoid split approach method and locked ana-tomic plate screw osteosynthesis. In group 1 patients, the space in the area where valgization is present in the head was filled with cortico-cancellous allografts. No grafting or metaphyseal compression took place in Group 2 patients. In group 3 patients, the metaphyseal compression technique was applied to the bone defect area. Cephalodiaphyseal angles (CDA) were measured at the postoperative and final follow-up. The constant Murley score made the functional evaluation. RESULTS: The patients were followed for an average of 27.6 months, and the union was present in all patients for an average of 3.6 months. Early screw migration was present in three patients, and late screw migration was in one patient. There were twenty-four excellent and 5 good results. CDA decreased from 139.42° to 136.13°. A statistically significant difference was present between the values of Groups 2 and 3 in the final control CDA of the groups. CONCLUSION: In this study, the functional scores of grafting stable valgus-impacted fractures and metaphyseal compression of unstable fractures with insufficient medial support were as good as stable 3-part fractures. Considering neer type 3 fractures should be evaluated with their subgroups, and fixation and stability-enhancing solutions specific to the groups are essential.

Endobutton Fixation Technique for Multifragmented Coronoid Fractures.

Coronoid fractures commonly occur in a part of unstable elbow fractures. Stable coronoid fracture fixation is important for early elbow motion. It may be difficult to fix multifragmented coronoid process fractures with loose capsular attachment. Thus, we demonstrated the endobutton suspensory technique to fix the anterior coronoidal fragments due to its suspensory effect providing capsular attachment. This technique allows stable fixation to the small multifragmented coronoid fractures with early range of motion.

A minimally invasive fixation technique for selected patients with fifth metacarpal neck fracture.

OBJECTIVE: The objective of this study was to compare the short-term results of treatment of fifth metacarpal neck fractures using a minimally invasive surgical fixation technique and the gold standard splinting method in a selected patient group of office workers with high expectations. PATIENTS AND METHODS: Twenty-four male patients (mean age: 28 years, range: 18-46 years) satisfying the inclusion criteria were enrolled in the study in two groups: surgical treatment and splinting (U-shaped ulnar gutter) groups. Hygienic interactions during daily activities and the use of keyboard and pens were allowed in the posttreatment period. The Short Form-Disabilities of the Arm, Shoulder and Hand Score (DASH) questionnaire was used to assess patient satisfaction and functionality of the extremity on the 30th and 45th days. Joint ranges of motion were measured on the 45th day. Functional and radiological evaluation data were analyzed statistically. RESULTS: In the conservative treatment group, initial palmar angulation was measured to be 42.6°, whereas a mean of 13.5° was noted and metacarpal shortening of 5.6mm decreased to 2mm after treatment, respectively. In terms of total joint range of motion (ROM), flexion of the treated side was at 91.25% and extension at 92.5% when measured versus the healthy-side values at the final follow-up. The mean time for return to work in this group was 33.6 days. The mean Quick-DASH score on the 30th-day follow-up was 69.5, whereas it was 39.3 at the 45th-day follow-up. The radiological findings showed a correction of the mean palmar angulation from 43° to 8° at follow-up in the surgically treated group. The initial metacarpal shortening of 9.3mm improved to 0.5mm at final examination. In terms of total joint ROM, flexion of the treated side was at 94% and extension at 95.5% when measured versus the healthy-side values on the 45th-day follow-ups. The mean time for return to work was 3.9 days. The mean Quick-DASH score on the 30th-day follow-up was 2.96, whereas it was noted as 0.69 at the 45th-day follow-up. CONCLUSIONS: We recommend antegrade intramedullary K-wire fixation as a reliable method, which minimizes the functional loss and allows for early return to daily activities in office workers who sustained a fracture of the fifth metacarpal neck.

Management and Prognostic Factors for Delayed Reconstruction of Neglected Posterior Shoulder Fracture-Dislocation.

INTRODUCTION: Posterior fracture-dislocations of the shoulder are rare conditions. Misdiagnosis can occur in 50% - 80% of the patients. Due to the size of the lesion, stability of the joint could not be achieved with transfer of subscapular tendon or tuberosity. CASE PRESENTATION: A 54-year-old male patient was referred to our hospital with a neglected posterior shoulder fracture-dislocation. Functional results of the patient, and technical informations were explained in this case report. The reverse Hill-Sachs lesion involved 40% of the articular surface. Depressed and malunited fragment was elevated, and fixated to the humeral head. CONCLUSIONS: Glenohumeral joint reduction with reconstruction of the humeral head seems to be possible even in a neglected locked posterior shoulder fracture-dislocation. If the depressed osteochondral fragment is still spheric, signs of the avascular necrosis are absent on CT, and malunion of the fragment has occurred, it is quite possible to reconstruct the head. Although results of the case are good, it is worthwhile to follow these patients for long-term complications.

Intra-articular polyacrylamide hydrogel injections are not innocent.

Osteoarthritis is a chronic disorder characterized by joint cartilage degeneration with concomitant changes in the synovium and subchondral bone metabolism. Many conservative treatment modalities, one of which is intra-articular injections, have been described for the treatment of this disorder. Traditionally, hyaluranic acid and corticosteroids are the agents that have been used for this purpose. Recently, polyacrylamide hydrogels are being used widely. Biocompatibility, nonbioabsorbability, and anti-infectious effect obtained by silver addition made polyacrylamide hydrogels more popular. In this paper, we present a case and the method of our management, in whom host tissue reaction (foreign body granuloma, edema, inflammation, and redness induration) has been observed, as the first and unique adverse effect reported in the literature.

[Early results of medial opening wedge osteotomy in varus gonarthrosis]. / Varus gonartrozunda medial açik kama osteotomisinin erken dönem sonuçlari.

OBJECTIVES: We evaluated the efficacy and short-term results of medial opening wedge high tibial osteotomy with the use of a Puddu plate in patients with medial compartment gonarthrosis. METHODS: The study included 15 knees of 12 female patients (mean age 50.6 years; range 45 to 63 years) who were treated with medial opening wedge high tibial osteotomy for varus knees with medial compartment gonarthrosis. The osteotomy sites were fixed with a Puddu plate followed by allograft application. The mean follow-up period was 30.7 months (range 19 to 40 months). RESULTS: The mean consolidation time was 7.1 weeks (range 6 to 9 weeks). The mean preoperative and postoperative Lysholm scores were 54.1 (range 30 to 60) and 82 (range 67 to 95), respectively. The mean preoperative femorotibial angle was 3.5 degrees in varus malalignment (range 3 degrees valgus to 9 degrees varus). It was 7.3 degrees valgus postoperatively. The mean correction of the mechanical axis was 10.7 degrees , with no loss of correction during the follow-up period. No adverse effects were observed associated with allograft use. The lateral cortex was broken in one patient (6.7%) who was then treated with an Ilizarov external fixator due to pseudoarthrosis. All but this patient were satisfied with the treatment. CONCLUSION: Compared with other osteotomy models, medial opening wedge osteotomy with the use of a Puddu plate offers advantages in terms of ease of application and maintenance of correction in the early follow-up period. With allograft application, consolidation is obtained without interfering with the rehabilitation period.

[Early results of treatment with expandable intramedullary nails in femur shaft fractures]. / Femur saft kiriklarinda genisleyebilir intramedüller çivilerle erken dönem tedavi sonuçlari.

OBJECTIVES: We evaluated the use of expandable intramedullary nails, their efficacy, and short-term results in the treatment of femur shaft fractures. METHODS: The study included 20 patients (10 females, 10 males; mean age 31 years; range 15 to 75 years) who were treated with expandable intramedullary nails (Fixion intramedullary femur nail) for femur shaft fractures. All the fractures were closed and were rated as type 32 A or B according to the AO classification. The mean duration from injury to surgery was three days (range 4 hours to 8 days). The results were evaluated using the Thoresen criteria. The mean follow-up was 26 months (range 9 to 38 months). RESULTS: The mean operation time was 79 minutes (range 45 to 120 min). Union was achieved in all the patients in a mean of 12.8 weeks (range 10 to 20 weeks). According to the Thoresen criteria, the results were excellent in 15 patients, good in one patient, fair in three patients, and poor in one patient. The results in all type A middle diaphyseal fractures were excellent. Of four patients with A2-3 distal metadiaphyseal fractures, one patient had a good result with a valgus of 5 degrees , and three patients had a fair result with a valgus ranging from 8 degrees to 10 degrees , one of which also had 8-mm shortening. Delayed union, early or late infections, compartment syndrome, or bone necrosis were not seen. Of six patients who completed a follow-up of two years, the nails were removed in five patients, whereas removal was not possible in one patient due to a break in the upper part. CONCLUSION: Expandable intramedullary nails offer advantages in terms of ease of application and are less invasive than static nails and reamed applications. However, they may not provide adequate stability in metadiaphyseal regions and in fractures with fragments greater than 50%.

[The results of arthroscopic repair in partial rotator cuff tears]. / Rotator mansetin kismi yirtiklarinda artroskopik tedavi sonuçlari.

OBJECTIVES: We evaluated patients who underwent arthroscopic repair for partial rotator cuff tears less than 50% of tendon thickness with respect to the course of tears and functional results. METHODS: Nineteen patients (10 women, 9 men; mean age 49 years; range 40 to 70 years) who did not benefit from conservative treatment for partial rotator cuff tears were treated with arthroscopic debridement with or without subacromial decompression. Twelve patients had a history of trauma before the appearance of complaints which had a mean duration of 12 months (range 7 to 24 months) before arthroscopic repair. Partial tears were on the articular side in 12 patients, and on the bursal side in seven patients. The patients were assessed with preoperative and postoperative physical examination, magnetic resonance imaging (MRI), and UCLA scores. RESULTS: The mean preoperative and postoperative UCLA scores were 16.8 (range 10 to 20) and 29.0 (range 9 to 35), respectively (p<0.05). The results were excellent or good in 14 patients (73.7%), fair in two patients (10.5%), and poor in three patients (15.8%). One patient developed shoulder stiffness which improved following rehabilitation. Postoperative MRI showed persistence of partial tears in 13 patients, progression in five patients, and development of total rupture in one patient. Complaints of pain increased in severity in patients in whom partial tears manifested a progressive course. One patient with total rupture underwent mini-open rotator cuff repair in the postoperative sixth month. CONCLUSION: Although clinical symptoms show improvement in most of the patients following arthroscopic treatment, partial rotator cuff tears do not heal completely in a considerable number of cases, and may progress to full-thickness tears in some.

[The results of arthroscopic Bankart repair with suture anchors]. / Dikis kancalariyla artroskopik Bankart tamirinin sonuçlari.

OBJECTIVES: We evaluated the results of arthroscopic Bankart repair in patients with postraumatic recurrent anterior glenohumeral instability. METHODS: Sixteen patients (1 female, 15 males; mean age 29 years; range 17 to 37 years) underwent arthroscopic Bankart repair with suture anchors for posttraumatic recurrent anterior glenohumeral instability. Involvement was on the right side in 11 patients, on the left in five patients, and on the dominant side in 14 patients. The range of motion was assessed with a goniometer and muscle strength manually. Pre- and postoperative evaluations included physical examination, the Rowe scale for shoulder functions, anteroposterior and axillary radiographs, and magnetic resonance imaging. The mean follow-up was 32.9 months (range 24 to 55 months). RESULTS: The mean number of dislocations was eight (range 2 to 18) and the mean time from the first dislocation to surgery was 4.6 years (range 6 months to 18 years). The mean preoperative active forward elevation was 148 degrees , and active external rotation was 45 degrees , which increased postoperatively to 160 degrees and 48 degrees , respectively (p<0.05). According to the Rowe scale, the results were excellent or good in 12 patients (75.0%), fair in three patients (18.8%), and poor in one patient (6.3%). All the patients returned to work in a mean of 3.6 months (range 2 to 6 months). Thirteen patients (81.3%) were satisfied with the operation. CONCLUSION: Successful results following arthroscopic Bankart repair with suture anchors are related to the restoration of the exact pathologic anatomy. Identification of patients with evident capsular laxity and addition of capsular plication to the procedure to eliminate this laxity may contribute to higher success rates.

[Early results of treatment with expandable intramedullary nails in tibia shaft fractures]. / Tibia saft kiriklarinda genisleyebilir intramedüller çivilerle erken dönem tedavi sonuçlari.

OBJECTIVES: We evaluated the use of expandable intramedullary nails, their efficacy, and short-term results in the treatment of tibia shaft fractures. METHODS: The study included 19 patients (8 females, 11 males; mean age 38 years; range 17 to 65 years) who were treated with expandable intramedullary nails (Fixion) for tibia shaft fractures. All the fractures were closed. Four patients had associated injuries. According to the AO classification, the fractures were type 42-A, B, or C. The mean duration from injury to surgery was 2.8 days (range 6 hours to 14 days). The results were evaluated using the Johner-Wruhs criteria. The mean follow-up was 23 months (range 9 to 39 months). RESULTS: The mean operation time was 47 minutes (range 25 to 53 min). Union was achieved in all the patients in a mean of 11.5 weeks (range 8 to 18 weeks). According to the Johner-Wruhs criteria, the results were excellent in 17 patients (89.5%) and good in two patients (10.5%). Treatment of fragmented-oblique fractures of the distal metadiaphysis (42-B2) resulted in a valgus angulation of 5 degrees in two patients, and extremity shortening of 5 mm in one patient, both of whom had good results. Complications such as delayed union, early or late infections, or bone necrosis did not occur. The range of motion of the knee and ankle reached that of the contralateral side in all the patients. CONCLUSION: Expandable intramedullary nails offer advantages in terms of ease of application and are less invasive than static nails and reamed applications. However, they may not provide adequate stability in fractures with fragments greater than 50%.

Malignant triton tumor of the lumbar spine.

STUDY DESIGN: A case report of surgically treated malignant triton tumor of the L2 nerve root. OBJECTIVES: To discuss treatment methods of the rare malignant triton tumor. SUMMARY OF BACKGROUND DATA: Malignant peripheral nerve sheath tumors are neoplasms that most often arise in peripheral nerves or in neurofibromas. Malignant triton tumor is a histologic variant of those tumors. METHODS: A 58-years-old male patient was admitted with severe back and leg pain. Magnetic resonance imaging revealed a dumbbell-shaped tumor over the right L2 nerve root. The tumor mass was removed posteriorly and the spine was stabilized by transpedicular screws followed by radiation therapy. RESULTS: The tumor was diagnosed as "malignant triton tumor." There was no sign of metastasis during the 8 months of follow up. CONCLUSIONS: In this case, the diagnosis of triton tumor is based solely on microscopic evidence of the neural tissue accompanied by rhabdomyoblasts and immunohistochemical examination. Patients with malignant triton tumors are usually younger than age 35. Our patient is 1 of the oldest patients with tumor occurrence in the spinal canal. Although our patient still has no evidence of recurrence, the prognosis is poor for this group of patients.

[Early treatment results with expandable intramedullary nails in lower extremity shaft fractures]. / Alt ekstremite saft kiriklarinda genisleyebilir intramedüller çivilerle erken dönem tedavi sonuçlari.

BACKGROUND: We investigated the use of expandable intramedullary nails, their efficacy, and short term results in the treatment of lower extremity shaft fractures. METHODS: The study included 23 patients (10 females, 13 males; mean age 33 years; range 17 to 60 years) who were treated with expandable intramedullary nails (the Fixion nail) for the lower extremity shaft fractures. Fourteen patients had femoral, nine patients had tibial fractures, all of which were closed. Eight patients had associated injuries. The mean duration from injury to surgery was 3.2 days (range 24 hours to 14 days). The results were evaluated using the Kalström-Olerud criteria. The mean follow-up was 15.3 months (range 10 to 20 months) for tibial fractures, and 13.1 months (range 10 to 19 months) for femoral fractures. RESULTS: Union was achieved in all the patients. In tibial fractures, the mean operation time was 50 minutes (range 25 to 90 min) and the mean time to union was 12 weeks (range 8 to 24 weeks). The results were excellent in six patients, and good in three patients. In femoral fractures, the mean operation time was 83.5 minutes (range 55 to 120 min) and the mean time to union was 13.2 weeks (range 10 to 20 weeks). The results were excellent in eight patients, good in three patients, fair in two patients, and poor in one patient. No complications were seen such as delayed union, early or late infections, compartment syndrome, or bone necrosis. CONCLUSION: Expandable intramedullary nails offer advantages in terms of ease of application and are less invasive than static nails and reamed applications. However, they may not provide adequate stability in metadiaphyseal regions and in fractures with fragments larger than 50 per cent.