Is depression associated with functional recovery after hip fracture in the elderly?

AIM: The aim of this study was to examine the effects of depression on functional healing and the return to pre-fracture daily activities in elderly patients with a hip fracture. METHODS: The study comprised 104 elderly patients, who had a unilateral hip fracture between 2009 and 2012. To evaluate daily activities and functional healing of the cases, the study was designed as a prospective comparative study. RESULTS: The analysis results revealed that the change in the mean ADL scores was related to depression at a statistically significant level (p = 0.000). DISCUSSION: This study results showed that depression had a negative effect on the daily activity level of these cases.

The Intramedullary Nailing of Adult Femoral Shaft Fracture by the Way of Open Reduction is a Disadvantage or Not?

The purpose of this study is that to evaluate superiority and results of open technique in the treatment of femoral shaft fracture with interlocking intramedullary nailing. The retrospective study is designed to evaluate results of our technique. In this study, the patients that were admitted to the Orthopedics and Traumatology Department of University Hospital that is third level of trauma center. We claim that open technique is not a disadvantage during union process over closed technique in treatment of femoral shaft fracture with interlocking nailing. In this study, 44 patients that were consulted for adult femoral shaft fracture between January 2008 to July 2010 were included. Patients with open fractures, gunshot wounds, neurovascular injuries, and patients that did not have isolated femoral diaphysis fractures were excluded from the study. Clinical and radiological results of the patients were checked periodically. The open interlocking intramedullary nailing was used in treatment. Complete union rate was 90.9 % in 40 patients who were treated with open interlocking intramedullary nailing for adult femoral shaft fracture, and nonunion rate was 9.1 % in four patients. Mean union time was 18.3 weeks (12-36 weeks). Evaluation of 44 patients according to Thoresen criteria was excellent in 22 patients, good in 6 patients, and bad in 4 patients. We think that open technique is an acceptable technique because all results of our study were similar to results of closed intramedullary nailing technique in literature and some advantages of open technique over closed technique.

Comparison of lag screw versus buttress plate fixation of posterior malleolar fractures.

BACKGROUND: The goal of this study was to report the results of selective open reduction and internal fixation of fractures of the posterior malleolus with a posterolateral approach and to compare the results of the 2 techniques. METHODS: We prospectively evaluated 40 patients who underwent posterior malleolar fracture fixation between 2008 and 2012. The patients were treated with a posterolateral approach. We assigned alternating patients to receive plate fixation and the next screw fixation, consecutively, based on the order in which they presented to our institution. Fixation of the posterior malleolus was made with lag screws in 20 patients and a buttress plate in 20 patients. We used American Orthopaedic Foot and Ankle Society (AOFAS) scores, range of motion (ROM) of the ankle, and radiographic evaluations as the main outcome measurements. The mean follow-up was 38.2 (range, 24-51) months. RESULTS: Full union without any loss of reduction was obtained in 38 of the 40 patients. We detected a union with a step-off of 3 mm in 1 patient in the screw group and a step-off of 2 mm in 1 patient in the plate group. At the final follow-up, the mean AOFAS score of the patients regardless of fixation type was 94.1 (range, 85-100). The statistical results showed no significant difference between the patients regardless of the fixation type of the posterior malleolus in terms of AOFAS scores and ROM of the ankle (P > .05). CONCLUSIONS: Good (AOFAS score of 94/100) and equivalent (within 3 points) results were obtained using the 2 techniques (screws or plate) for fixation after open reduction of posterior malleolar fragments. LEVEL OF EVIDENCE: Level II, prospective case series.

Is scintigraphy a guideline method in determining amputation levels in diabetic foot?

BACKGROUND: In this study, we aimed to evaluate the potential use of a 3-phase bone scintigraphy method to determine the level of amputation on treatment cost, morbidity and mortality, reamputation rates, and the duration of hospitalization in diabetic foot. METHODS: Thirty patients who were admitted to our clinic between September 2008 and July 2009, with diabetic foot were included. All patients were evaluated according to age, gender, diabetes duration, 3-phase bone scintigraphy, Doppler ultrasound, amputation/reamputation levels, and hospitalization periods. Patients underwent 3-phase bone scintigraphy using technetium-99m methylene diphosphonate, and the most distal site of the region displaying perfusion during the perfusion and early blood flow phase was marked as the amputation level. Amputation level was determined by 3-phase bone scintigraphy, Doppler ultrasound, and inspection of the infection-free clear region during surgery. RESULTS: The amputation levels of the patients were as follows: finger in six (20%), ray amputation in five (16.6%), transmetatarsal in one (3.3%), Lisfranc in two (6.6%), Chopart in seven (23.3%), Syme in one (3.3%), below-the-knee in six (20%), above the knee in one (3.3%), knee disarticulation in one (3.3%), and two patients underwent amputation at other centers. After primary amputation, reamputation was performed on seven patients, and one patient was treated with debridement for wound site problems. No mortality was encountered during study. CONCLUSIONS: We conclude that 3-phase bone scintigraphy prior to surgery could be a useful method to determine the amputation level in a diabetic foot. We conclude that further, comparative, more comprehensive, long-term, and controlled studies are required.

Effect of Pentoxifylline on Spinal Fusion: An Experimental Study in Rabbits.

STUDY DESIGN: Randomized, double-blinded, animal model. OBJECTIVE: The objective of this study is to evaluate the effect of pentoxifylline (PTX) on spinal fusion in a rabbit model. SUMMARY OF BACKGROUND DATA: Previous studies assert that PTX increases new bone formation. Because PTX seems to have these profound effects on bone metabolism, it may be hypothesized that it may enhance spinal fusion. METHODS: Twenty-four New Zealand white rabbits were randomized and each received single-level posterolateral, inter-transverse process fusion with autologous iliac crest. In group 1, 12 male New Zealand white rabbits were treated with intravenous PTX treatment in 100-mg/kg/day dose after the surgical procedure. In group 2, 12 received no PTX medication and were accepted as the control group. Nine weeks after surgery, the animals were killed. The spines were tested via a manual palpation test, biomechanical testing, plain radiography, computed tomographic scans, and histomorphometric analysis. RESULTS: The fusion rates of manual palpation were 40% in the control group and 80% in the PTX group (P = 0.17). Using a 5-grade radiographical system, the mean fusion grade was 2.4 in the control group and 3.1 in PTX group (P = 0.012). Total displacement of the fused level for the control group under flexion and extension was 0.2515 mm and was lower for the PTX-treated group: 0.1266 mm (P = 0.012). In the control group, the mean bone volume of the fusion mass determined from computed tomographic analysis was 4.0678 cm, whereas in the PTX group it was 4.7802 cm (P = 0.009). The mean trabecular bone area was 14% and 19% for the control and PTX groups, respectively (P = 0.002). CONCLUSION: The differences between groups was statistically significant in terms of radiological fusion grading, biomechanical testing, volume of the fusion mass, and percentage of trabecular bone area. These results suggest that PTX may have a beneficial effect on spinal fusion. LEVEL OF EVIDENCE: 2.

Disagreements in surgical planning still exist between spinal surgeons in adolescent idiopathic scoliosis: a multisurgeon assessment.

PURPOSE: Determining a surgical plan for the treatment of adolescent idiopathic scoliosis (AIS) can be challenging. Despite treatment recommendations and classification systems (such as the Lenke classification system) there is still no consensus on the optimal surgical plan for each curve type. The main objective of this study is to analyze the disagreements in surgical planning between spinal surgeons in AIS. METHODS: In a monthly meeting, four orthopaedic spine surgeons from different institutions analyzed a consecutive series of AIS patients. The differences in surgical plans were evaluated for each patient. The primary physician of the patient presented the case and specifically stated the Lenke type of the deformity in the presentation. We wanted to specifically document the disagreements between surgeons despite knowing the Lenke type of the deformity. RESULTS: One hundred consecutive AIS patients were reviewed over a 10-month period. There was a difference of at least one surgical plan from at least one surgeon in 31 of the cases; 30 of these disagreements in surgical planning were about fusion levels; 19 of these 30 disagreements were in only the upper instrumented vertebra (UIV), while seven were disagreements in only the lowest instrumented vertebra (LIV). In four cases, both the UIV and LIV levels varied. CONCLUSIONS: There was at least one difference in surgical planning in 31 of the 100 cases (31 %). This shows that despite treatment algorithms and the Lenke classification system, disagreements in surgical planning still exist between spinal surgeons.

A new method for the measurement of anteversion of the acetabular cup after total hip arthroplasty.

OBJECTIVE: Many methods of determining the anteversion of the acetabular cup have been described in the literature. The advantages and disadvantages of each of these methods are discussed in this paper. We present a new method of measuring the acetabular anteversion at the anteroposterior hip. MATERIALS AND METHODS: The formula designed by the authors was anteversion angle (α) = arc sin |PK|/√ |AK| × |BK|. The formula was tested using the AutoCAD software, and an experimental study was conducted to evaluate the accuracy. Three groups were created, and 16 X-ray images were taken and coded. Ten orthopaedic surgeons measured the acetabular anteversion from these X-rays using our formula. RESULTS: The results in Group 1 were closer to the actual value; in contrast, the results in Group 2 differed from the actual values. The results in Group 3 were as close to the actual anteversion values as were those in Group 1. CONCLUSION: Developments in technology often bring an increase in complications. Despite newly developed surgical methods and technology, the position of the acetabular cup is still used to determine the results of a total hip arthroplasty. Our method is simple, cost-effective and achieves almost 100 % accuracy.

Can radiation exposure to the surgeon be reduced with freehand pedicle screw fixation technique in pediatric spinal deformity correction? A prospective multicenter study.

STUDY DESIGN: Prospective multicenter study of patients who underwent pediatric spinal deformity correction with posterior spinal fusion and instrumentation. OBJECTIVE: To quantify radiation exposure to the surgeon during pedicle screw fixation using the freehand technique in pediatric spinal deformity surgery. SUMMARY OF BACKGROUND DATA: Pedicle screw placement in thoracic and lumbar spine for spinal deformity is technically demanding and involves radiation exposure. Many experienced spinals surgeons use the freehand technique for pedicle screw fixation in spinal deformity surgery. There are no studies analyzing radiation exposure to the surgeon regarding freehand pedicle screw fixation technique. METHODS: A prospective multicenter study was designed to evaluate radiation exposure to the operating spinal surgeon who uses the freehand pedicle screw fixation technique in pediatric spinal deformity correction. All of the operating surgeons placed a gamma radiation dosimeter on their chest outside the lead apron during surgery. Surgeons placed pedicle screws in the pediatric spinal deformity using the freehand technique. We included patients who had undergone correction with posterior spinal fusion and instrumentation with all pedicle screw constructs in this study. RESULTS: We analyzed 125 patients with pediatric spinal deformity who were operated on between 2008 and 2012. The average fluoroscopic time was 40.5 ± 21 seconds. The overall average fluoroscopic time for placement of a single pedicle screw and per fixation level were 2.6 ± 1.7 seconds and 3.9 ± 2.5 seconds, respectively. In each surgery, the recorded radiation exposure to the surgeon was less than the minimum reportable dose (<0.010 mSv) with an average of 0.0005 ± 0.00013 mSv per surgery. CONCLUSION: The use of freehand technique for pedicle screw fixation in spinal deformity correction requires a minimum amount of fluoroscopic use, hence decreasing radiation exposure to the surgeon and patient. LEVEL OF EVIDENCE: 4.

Results of vacuum assisted wound closure application.

In recent past, various methods have been used for wound treatment purpose. In this study, we aimed to compare our results established from the vacuum-assisted wound closure method, which has gained popularity day by day, with the literature. A total of 48 patients, who received vacuum-assisted wound closure treatment in our clinic between 2007and 2010, were included in this study. Etiological distribution of the patients was as follows: 32 traumatic, 6 pressure sore, 9 diabetic, and 1 iliac disarticulation. All cases were evaluated in terms of age, gender, etiology, period of treatment, and size of the wound. In the patients studied, 42 were men (87.5 %) and 6 were women (12.5 %). Mean age of the patients was 39.6 years (11-61 years). All of our traumatic patients suffered from open fracture. After the vacuum-assisted wound closure application, wound size reduced by 28.8 %, while the mean area of the surface of the wound was 94.7 cm(2) (13.7-216.3 cm(2)) on average. After the wounds became ready for surgery, 15 of them were treated with split-thickness grafting, 9 of them were treated with secondary suture, 18 of them were treated with full-thickness grafting, and 6 of them were treated with flap. Average period of the application of vacuum-assisted wound closure was 11.6 days (7-15 days). Results of vacuum-assisted wound closure can be regarded as satisfactory when cases are selected properly. This system has three different effect mechanisms. Firstly, it increases local blood flow on the wound bed. Secondly, cell proliferation is triggered following the mechanic stress. Thirdly, vacuum removes the proteases from the environment which obstructs healing. Therefore, it is intended to prepare alive wound bed which is required for subsequent soft tissue reconstructions.

[Treatment of adult tibial diaphysis fractures with reamed and locked intramedullary nailing]. / Tibia diyafiz kiriklarinin oymali kilitli intramedüller çivi ile tedavisi.

OBJECTIVES: We evaluated the results of reamed and locked intramedullary nailing for tibial diaphysis fractures. METHODS: The study included 73 patients (68 males, 5 females; mean age 31 years; range 17 to 68 years) who were treated with reamed and locked intramedullary nailing for tibial diaphysis fractures. There were 28 AO/ASIF type A, 29 type B, and 16 type C fractures. The fractures involved the proximal 1/3 (n=12), middle 1/3 (n=50), and distal 1/3 (n=11) of the tibial diaphysis. Twenty-eight fractures (38.4%) were closed. According to the Gustilo-Anderson classification, 30 patients (41.1%) had grade I, 10 patients (13.7%) had grade II, and five patients (6.9%) had grade IIIA open fractures. Intramedullary nailing was performed following open reduction in 17 patients (23.3%), and closed reduction in 56 patients (76.7%). The mean time to surgery was 3.4 days (range 2 to 11 days) and the mean follow-up was 48 months (range 24 to 60 months). The patients were evaluated with respect to range of motion, time to union, and complications. Functional results were assessed using the Johner-Wrush criteria. RESULTS: Union was achieved in all the patients within a mean of 18.2 weeks (range 8 to 52 weeks). Four patients required dynamization because of delayed union and grafting was performed in one patient. Transient sensorial deficit occurred in one patient after dynamization. One patient underwent revision surgery because of migration of the distal locking screws. The only limitation of range of motion was seen in flexion of two patients (2.7%) who developed anterior knee pain. According to the Johner-Wrush criteria, functional results were very good in 45 patients (61.6%), and good in 28 patients (38.4%). CONCLUSION: Treatment of tibial diaphysis fractures with reamed and locked intramedullary nailing is an appropriate choice with a low complication rate. It can be safely used in moderately contaminated open fractures.

Complications encountered during lengthening over an intramedullary nail.

BACKGROUND: In limb-lengthening, the quest for increased patient comfort and a reduced period of external fixation has led to techniques such as lengthening over an intramedullary nail. The goals of this study were to investigate the rate and types of complications encountered during lengthening over an intramedullary nail and to identify solutions to these complications. METHODS: Forty-two segments (thirty-five femora and seven tibiae) in thirty-five patients were lengthened. The mean age of the patients was 26.6 years, the mean amount lengthened was 6.3 cm (range, 2.5 to 11.5 cm), the mean external fixation index was 18.7 days/cm, and the mean lengthening index was 31.2 days/cm. The patients were followed for a mean period of forty-four months postoperatively. RESULTS: Eighteen complications occurred in sixteen (38%) of the forty-two segments for a rate of 0.43 complication per segment. Complications were classified, according to the system of Paley et al., as two problems, thirteen obstacles, and three sequelae. Sixteen of them required additional surgical interventions. A preoperative score of >6.5 on the system of Paley et al., a lengthening of >6 cm, and a lengthening percentage of >21.5% of the original bone length were indicators of a higher probability of the occurrence of complications. CONCLUSIONS: Lengthening over an intramedullary nail provides increased patient comfort and reduces the external fixation period. If the problems encountered are treated aggressively, the result of the treatment can be quite satisfactory.