IS FUNCTIONAL OUTCOME BETTER AFTER ARTHROPLASTY FOR TROCHANTERIC FRACTURES IN OLDER ADULTS?

OBJECTIVES: This article evaluated functional recovery and mortality after surgery to repair trochanteric fracture with regard to treatment technique through one year of follow-up. METHOD: Eighty consecutive patients with trochanteric fractures were divided into two groups according to treatment technique (osteosynthesis and arthroplasty). We evaluated patient data including age, sex, time to surgery, total hospital stay, transfusion volume, and functional status according to FIM (Functional Independence Measure) scores. Scores for FIM were assessed three times: prior to fracture, six months after surgery, and one year after surgery. RESULTS: Patients who received osteosynthesis had shorter hospital stays than arthroplasty patients. The arthroplasty group had significantly higher functional independence six months after surgery, while no difference was detected one year after surgery. Patient age, transfusion volume, and FIM scores were detected as significant predictors of mortality. CONCLUSION: Trochanteric fractures lead to unavoidable functional loss, although this can be reduced in the short term by treating with arthroplasty instead of osteosynthesis. Age, transfusion and functional situation predict one-year mortality for patients with trochanteric fractures. The patient's functional situation must be considered when choosing treatment for trochanteric fractures in order to reduce patient morbidity. Level of Evidence II; Therapeutic prospective study.

OBJETIVO: Este artigo avaliou a recuperação funcional e a mortalidade após cirurgia de fratura do quadril com relação à técnica de tratamento durante um ano de acompanhamento. MÉTODO: Oitenta pacientes consecutivos com fraturas trocantéricas foram divididos em dois grupos, de acordo com a técnica de tratamento (osteossíntese e artroplastia). Avaliamos os dados dos pacientes quanto a idade, sexo, tempo até a cirurgia, estadia hospitalar total, volume de transfusão e estado funcional de acordo com a pontuação da MIF (Medida de Independência Funcional). A MIF foi avaliada três vezes: antes da fratura, seis meses e um ano após a cirurgia. RESULTADOS: Os pacientes submetidos à osteossíntese tiveram menor tempo de hospitalização do que os pacientes de artroplastia. O grupo artroplastia teve independência funcional significativamente maior seis meses depois da cirurgia, enquanto nenhuma diferença foi detectada um ano após a cirurgia. Idade, volume da transfusão e a pontuação MIF dos pacientes foram detectadas como preditores importantes da mortalidade. CONCLUSÃO: As fraturas trocantéricas levam à perda funcional inevitável, embora ela possa ser reduzida a curto prazo com a artroplastia ao invés da osteossíntese. A idade, a transfusão e a situação funcional são preditores significativos de mortalidade em um ano em pacientes com fraturas trocantéricas. A situação funcional dos pacientes deve ser considerada ao escolher o tratamento de fraturas trocantéricas para reduzir a morbidade dos pacientes. Nível de Evidência II; Estudo prospectivo terapêutico.

Is functional outcome better after arthroplasty for trochanteric fractures in older adults? / O resultado funcional é melhor depois da artroplastia para fraturas trocantéricas em idosos?

ABSTRACT Objectives: This article evaluated functional recovery and mortality after surgery to repair trochanteric fracture with regard to treatment technique through one year of follow-up. Method: Eighty consecutive patients with trochanteric fractures were divided into two groups according to treatment technique (osteosynthesis and arthroplasty). We evaluated patient data including age, sex, time to surgery, total hospital stay, transfusion volume, and functional status according to FIM (Functional Independence Measure) scores. Scores for FIM were assessed three times: prior to fracture, six months after surgery, and one year after surgery. Results: Patients who received osteosynthesis had shorter hospital stays than arthroplasty patients. The arthroplasty group had significantly higher functional independence six months after surgery, while no difference was detected one year after surgery. Patient age, transfusion volume, and FIM scores were detected as significant predictors of mortality. Conclusion: Trochanteric fractures lead to unavoidable functional loss, although this can be reduced in the short term by treating with arthroplasty instead of osteosynthesis. Age, transfusion and functional situation predict one-year mortality for patients with trochanteric fractures. The patient's functional situation must be considered when choosing treatment for trochanteric fractures in order to reduce patient morbidity. Level of Evidence II; Therapeutic prospective study.

RESUMO Objetivo: Este artigo avaliou a recuperação funcional e a mortalidade após cirurgia de fratura do quadril com relação à técnica de tratamento durante um ano de acompanhamento. Método: Oitenta pacientes consecutivos com fraturas trocantéricas foram divididos em dois grupos, de acordo com a técnica de tratamento (osteossíntese e artroplastia). Avaliamos os dados dos pacientes quanto a idade, sexo, tempo até a cirurgia, estadia hospitalar total, volume de transfusão e estado funcional de acordo com a pontuação da MIF (Medida de Independência Funcional). A MIF foi avaliada três vezes: antes da fratura, seis meses e um ano após a cirurgia. Resultados: Os pacientes submetidos à osteossíntese tiveram menor tempo de hospitalização do que os pacientes de artroplastia. O grupo artroplastia teve independência funcional significativamente maior seis meses depois da cirurgia, enquanto nenhuma diferença foi detectada um ano após a cirurgia. Idade, volume da transfusão e a pontuação MIF dos pacientes foram detectadas como preditores importantes da mortalidade. Conclusão: As fraturas trocantéricas levam à perda funcional inevitável, embora ela possa ser reduzida a curto prazo com a artroplastia ao invés da osteossíntese. A idade, a transfusão e a situação funcional são preditores significativos de mortalidade em um ano em pacientes com fraturas trocantéricas. A situação funcional dos pacientes deve ser considerada ao escolher o tratamento de fraturas trocantéricas para reduzir a morbidade dos pacientes. Nível de Evidência II; Estudo prospectivo terapêutico.

Anconeus interposition arthroplasty in acute multiligamentous elbow injuries with irreparable radial head fractures: a novel approach.

OBJECTIVE: The purpose of this study was to evaluate the results of a new reconstruction with anconeus interposition arthroplasty in acute multiligamentous elbow injuries with irreparable radial head fractures. METHODS: Five patients (3 males, 2 females) with a mean age of 42.6 years who underwent reconstruction with anconeus arhtroplasty were evaluated. With lateral approach, lateral capsuloligamentous structures were repaired, the radial head was excised, and anconeus interposition arthroplasty was performed. With medial intervention, the medial collateral ligament was repaired, and the ulnar nerve was transposed anteriorly. Clinical and radiological evaluation was performed the end of a mean follow-up period of 63 months. RESULTS: Mean Mayo Elbow Performance, Oxford Elbow, and Disabilities of the Arm, Shoulder and Hand (DASH) scores were 91, 41.4, and 13.76, respectively. Average elbow extension loss was 10.2° and average forearm supination loss was 5.2°. Dynamic elbow instability tests were within normal limits. On elbow radiographs, the average increase in cubitus valgus angle was 5.4°. No patient reported limitation in daily activities. There was no heterotopic ossification in any patient. Mean radial shortening was 1.39 mm, and no patient suffered from wrist pain at final follow-up. Average Mayo wrist score was 91 points. CONCLUSION: The combination of repair of the medial and lateral structures, radial head resection, and anconeus interposition arthroplasty may be a good alternative in the treatment of acute multiligamentous elbow injuries with irreparable radial head fracture.

Femoral insufficiency fractures in the elderly - excessive medial femoral bowing complicates intramedullary nailing.

OBJECTIVE: The aim of this study was to evaluate the characteristics of low-energy femoral insufficiency fractures in elderly patients. METHODS: The study retrospectively evaluated the clinical course of 4 patients with low-energy femoral shaft and subtrochanteric fractures admitted to our department between 2009 and 2011. Three patients had prior long-term alendronate therapy and one had prior glucocorticoid therapy. RESULTS: There were 5 femoral shaft fractures, 2 incomplete shaft fractures, 2 subtrochanteric and 1 intertrochanteric fractures. All femoral shaft fractures had characteristic fracture patterns with thickened lateral cortices at the proximal fragment. Six femurs had excessive medial femoral bowing, which complicated intramedullary nailing. Additional fractures were seen on both femurs of one patient who had been primarily treated with short implants. A bifocal femoral fracture was seen in one femur. Union was achieved in all patients. Two patients were able to walk independently, one with a cane and one with double crutches. CONCLUSION: We suggest the addition of another radiographic pattern of 'excessive medial femoral bowing' in low-energy femoral shaft fractures in elderly patients. This bowing complicates intramedullary nailing. Moreover, these insufficiency fractures should be fixed with long cephalomedullary nails.

Minimally invasive Achilles tendon repair: a modification of the Achillon technique.

BACKGROUND: The purpose of the study was to present the results of a new minimally invasive operative method for Achilles tendon (AT) ruptures that could reduce nerve injuries and add no extra cost. METHODS: Thirteen patients with acute AT ruptures who were treated with minimally invasive surgery and followed for a minimum of 12 months were included. At the latest follow-up, American Orthopaedic Foot & Ankle Society (AOFAS) score, calf diameters, ability to walk on tiptoe, and ultrasound examination were evaluated. The average age was 42.8 years (range, 31-62 years). Average follow up was 24.5 months (range, 12-34 months). RESULTS: AOFAS score was 92.5 (range, 85-100). Average calf diameters on the operated and nonoperated extremities were 38.9 cm (range, 36-44 cm) and 38.9 cm (range, 36-41 cm), respectively. On ultrasound examination, the site of the rupture was found to be 46.2 mm proximal from the calcaneal insertion, and the operated side was found to be significantly thicker than the nonoperated side (P = .008). There was 1 deep vein thrombosis, which recovered without sequelae. There were no wound problems, reruptures, or nerve injuries. CONCLUSIONS: This new minimally invasive operative method was successful, showing good functional results and low complication rates. In our experience, the use of 3 continuous polyester sutures was less irritable with 3 knots. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Application of rhenium-186 radiosynovectomy in elbow diffuse pigmented villonodular synovitis. - a case report with multiple joint involvement.

After surgical therapy of diffuse pigmented villonodular synovitis (DPVNS), recurrence is seen in almost half of the patients. The effectiveness of radiosynovectomy (RSV) in preventing recurrence and complaints of DPVNS is well known. Elbow involvement in DPVNS is a very rare condition; therefore, RSV in elbow hasn't been experienced widely. The aim of this case report is to show the effectiveness of RSV with rhenium-186 (Re-186) sulfide colloid. We applied Re-186 sulfide colloid to the elbow joint of DPVNS patients six weeks after arthroscopic synovectomy. As a result, the patient did not have any complaints, and our findings are compatible with residue or recurrence on magnetic resonance imaging (MRI) in sixth and twentieth month controls after administration. We concluded that Re-186 is an effective adjuvant therapy for the prevention of recurrence and complaints.

Pin site care during circular external fixation using two different protocols.

OBJECTIVES: Treatment of tibial fractures with Ilizarov external fixation is a valuable treatment alternative; however, development of problems at the pin site is one of the major drawbacks of this technique. Moreover, there is no general agreement regarding pin site care. The purpose of this study was to compare the efficacy of two different pin site care techniques after treatment of tibial fractures with an Ilizarov external fixator. DESIGN: Prospective randomized study. SETTING: Department of Orthopaedic Surgery of education and research hospital. PATIENTS AND METHODS: In this prospective randomized study, we followed up 610 pin sites in 39 cases using two different pin site care protocols. INTERVENTION: For the first 15 days, patients in both groups cleaned each pin site using sterile gauze impregnated with 10% polyvinylpyrrolidone iodine (Polyod) every 3 days. After 15 days, patients in group 1 (20 cases, 310 pin sites) were advised to perform pin care by daily showering and brushing the pin sites with soap and an ordinary soft toothbrush, whereas patients in group 2 (19 cases, 300 pin sites) were advised to perform pin care by daily showering and cleaning the crusts using sterile gauze impregnated with 10% polyvinylpyrrolidone iodine (Polyod). Each pin site was denominated according to location. MAIN OUTCOME MEASUREMENTS: Pin sites were inspected and graded on a scale of 0 to 5 according to slight modification of the system of Dahl described by Gordon et al during outpatient visits on the 5th, 10th, 15th, 30th, 45th, 60th, 75th, 90th, 120th, and 150th days of follow up after the operation until fixator removal. Grade 1 and grade 2 infections were categorized as minor infection not requiring any extra pin site care and grade 3 and above infections as major infection. RESULTS: Minor infection rate of all pin sites was determined as 50.7% in group 1 and 43.6% in group 2. Major infection rate was determined as 3.5% in group 1 and 3.7% in group 2. No statistically significant difference was noted between the two groups (all P > 0.05). CONCLUSION: Pin site care can be performed without impairing patient comfort and without prohibition of showering. Pin site care can be self-managed by the patients without complex sterilization techniques.

The use of a low-profile Ilizarov external fixator in the treatment of complex fractures and non-unions of the distal femur.

The aim of this study was to assess the effectiveness of a modified (low-profile) Ilizarov fixation in the treatment of complex fractures of the distal femur such asseptic or aseptic non-unions following previous surgeries, osteoporotic fractures, and high-grade open fractures. Ten male patients with a mean age of 50 years (range, 22-72 years) were treated with a modified Ilizarov fixator. The system was composed of tensioned olive wires attached to four 5/8 rings (two proximal and two distal to the fracture line) connected to each other with three rods. The fixator was not extended to the proximal femur nor across the knee to the tibia, and no Schanz screws were used. The main outcomes evaluated were union, time in fixator and IOWA knee score. Time in the fixator averaged 158 days (range, 125-180). Mean follow-up was 74 months (range, 24-108 months). All fractures united without major complications. One case healed with a 3 degrees varus angulation at the fracture site. The mean IOWA score was 83.8 (range, 70-98). Although superficial pin-tract infection was observed at 10 pin sites, no patient developed deep infection requiring premature pin removal. There was breakage of one wire, which was replaced under anaesthesia, and one patient presented a patella fracture after a fall, which healed after tension-band wire fixation. Considering the high union and low complication rates, we suggest the use of a low-profile Ilizarov fixator in the management of certain distal femoral fractures and non-unions that may be difficult to manage using other means of fixation.

Minimally invasive plating of the distal tibia: do we really sacrifice saphenous vein and nerve? A cadaver study.

OBJECTIVE: To investigate the risk of saphenous nerve (SN) and great saphenous vein (GSV) injury during percutaneous screw placement of the 3.5/4.5 LCP Distal Tibial Metaphyseal Plate and the 3.5-mm LCP Medial Distal Tibia Plate with tab in distal tibias of cadaver extremities. METHODS: Thirty-one unpaired (1 fresh and 30 formalin fixed) adult cadaveric lower extremity specimens were dissected. Using the principles of minimally invasive plating, a 3.5/4.5 LCP Distal Tibial Metaphyseal Plate was implanted in 16 extremities and a 3.5-mm LCP Medial Distal Tibia Plate with tab in the remaining 15 extremities. Injuries to or any evidences of direct contact with the SN or GSV were recorded. Additionally, the shortest distances of each hole to the main branches of these anatomic structures were measured. RESULTS: The risk of injury to the SN and GSV was higher in holes 4, 5, and 6 when using the 3.5/4.5 LCP Distal Tibial Metaphyseal Plate and in holes 3, 5, and 8 when using the 3.5-mm LCP Medial Distal Tibia Plate. CONCLUSIONS: The SN and GSV are at high risk for injury during percutaneous screw placement of the 3.5/4.5 LCP Distal Tibial Metaphyseal Plate and the 3.5-mm LCP Medial Distal Tibia Plate at the distal tibia. Careful dissection in the stab incisions down the plate, atraumatic placement of the drill sleeves, and protection of the soft tissues during screw insertion might decrease the risk of injury to the SN and GSV.

Rotator interval dimensions in different shoulder arthroscopy positions: a cadaveric study.

The rotator interval was defined as a triangular structure, where the base of the triangle was the coracoid base, the upper border was the anterior margin of the supraspinatus, and the lower border was the superior margin of the subscapularis muscle-tendon unit. We evaluated the rotator interval dimensions in 15 shoulders from 10 lightly embalmed adult cadavers in 3 shoulder arthroscopy positions: 0 degrees of abduction and 30 degrees of flexion (beach chair [BC]), 45 degrees of abduction and 30 degrees of flexion (lateral decubitus 1), and 70 degrees of abduction and 30 degrees of flexion (lateral decubitus 2). In each shoulder position, measurements were made in neutral rotation (NR), 45 degrees of external rotation (ER), and 45 degrees of internal rotation (IR). The coracoid base lengthened with IR in all positions and shortened in ER in the lateral decubitus position but not in the BC position. Abduction significantly lengthened the coracoid base, which was shortest in the BC position with ER (24 +/- 4 mm) and longest in the lateral decubitus 2 position with IR (33 +/- 5 mm). The coracoid base, where sutures are placed during plication of the interval, was observed to lengthen and, therefore, loosen with IR and abduction. To prevent postoperative ER restriction, plication should be made in ER or neutral rotation when operating in the BC position and the degree of abduction should be decreased and the shoulder held in ER when operating in the lateral decubitus position.

The safe distance for the superior gluteal nerve in direct lateral approach to the hip and its relation with the femoral length: a cadaver study.

INTRODUCTION: The most inferior branch (MIB) of the superior gluteal nerve (SGN) is vulnerable during direct lateral approach to the hip. A safe distance proximal to the tip of the greater trochanter varying from 3 to 5 cm has been reported in different studies. Anatomical studies defining safe zones and clinical studies reporting the results use various reference points, and the oblique course of the MIB contributes to the confusion. Numerous efforts have been made to standardize the safe zone using patient characteristics such as body height; however, contradictory results have been reported. The purpose of this study was to measure the safe distance in line to the gluteal split and also to determine the relationship of the safe distance with femoral length, as a stable component of body height. MATERIALS AND METHODS: Fifteen lower extremities of 12 formalin-fixed cadavers (M/F: 7/5) were dissected. The most prominent lateral palpable part of the trochanter major (TM) was determined and the dissection in the gluteus medius muscle (GMM) was performed starting from this point upwards in line of the muscle fibers. The distances between the MIB in the plane of dissection in the GMM to the TM and also to the trochanteric apex (TA) were measured. Femoral lengths were measured between the TM point and the lateral epicondyle. Spearman's correlation and Mann-Whitney U tests were used for statistical analysis. RESULTS: The SGN in 13 hips had spray pattern and neural trunk pattern in two. The plane of dissection was within the anterior third of the GMM in all hips. The average femoral length was 37.5 cm. Average distance between TM and MIB was 44 mm; in three hips, the distance was <30 mm. The average distance between TA and TM was 21 mm. There was no statistically significant correlation between femoral length and TM-MIB distance. CONCLUSION: The distance from the TM to the MIB is highly variable and independent from body height or femoral length. The so called "safe zone" in which damage of significant nerve damage is excluded can have a rather small dimension in some patients. Short patients are not at increased risk and tall patients are not risk free. Modern techniques in total hip replacement which try to minimize proximal interruption of the GMM are therefore justified.