Minimally invasive plate osteosynthesis (MIPO) in diaphyseal humerus and proximal humerus fractures.

OBJECTIVE: Our aim was to evaluate the results of minimally invasive plate osteosynthesis (MIPO) using locking plates in diaphyseal humerus and proximal humerus fractures. METHODS: Nine patients who underwent open reduction and MIPO for the treatment of diaphyseal and proximal humerus fractures between June 2006 and October 2009 were included in this study. One S3(®) and 8 PHILOS(®) plates were used. Mean age was 75.2 (range: 32 to 86) years and all patients were females. Mean follow-up was 33.9 (range: 14.8 to 54.8) months. According to AO/ASIF classification, four patients had 12C1, two patients 12A1, one patient 12A2, and two patients 11A2 fractures. Axillary and radial nerves were explored and protected in all patients. Patients were evaluated radiographically for union and functionally using the Constant-Murley score. RESULTS: None of the patients had nonunion, avascular necrosis, axillary or radial nerve paralysis or implant failure. Mean Constant-Murley score was 86.8 ± 2.2 (range: 70 to 100). Mean union time was 3.2 (range: 2.5 to 5) months. CONCLUSION: MIPO of humerus diaphysis and proximal fractures allows for preservation of blood supply in fracture fragments, owing to less soft tissue and periosteal injury. When the procedure is performed with the lateral double incision, exposure and preservation of the axillary and radial nerves are necessary. Early return of function in the shoulder and elbow joints and favorable healing time are the major advantages of this method in this rare subset of humerus fractures.

Simultaneous repair of chronic full-thickness rotator cuff tears during fixation of proximal humerus fractures and clinical results.

OBJECTIVES: We investigated the incidence of chronic rotator cuff tears encountered during fixation of proximal humerus fractures with locking plate-screw systems, and evaluated the functional results of simultaneous surgical repair of these injuries. METHODS: A total of 111 patients underwent surgical treatment for proximal humerus fractures. Of these, nine patients (8 females, 1 male; mean age 73 years; range 56 to 84 years) who had concomitant chronic full-thickness rotator cuff tears were included in the study. According to the AO classification, the fractures were type 11A1 (12C1 also present) in one patient, 11A2 (12C2 also present) in one patient, 11B1 in two patients, 11B2 in three patients, and 11C2 in two patients. None of the patients underwent preoperative magnetic resonance imaging. Fracture fixation was made with the PHILOS plate in five patients, and with the S3 Proximal Humerus Plate in four patients. All full-thickness rotator cuff tears were detected during the operation. Following open reduction and internal fixation after a deltoid splitting incision, rotator cuff tears were repaired by primary suture in two patients, and with a suture anchor in seven patients. All the patients used a padded shoulder-arm sling for six weeks and received a standard rehabilitation program. All the patients were evaluated radiographically and functionally using the Constant-Murley shoulder score at postoperative 6 weeks, 6 months, and 12 months. The mean follow-up period was 17.3 months (range 8 to 30 months). RESULTS: The incidence of full-thickness rotator cuff tears was 8.1%. All the patients had supraspinatus tears, which were accompanied by infraspinatus tears in three patients. The sizes of the tears were classified as large (between 3-5 cm) in three patients, intermediate (between 1-3 cm) in five patients, and small (<1 cm) in one patient. One patient had L-shaped, two patients had U-shaped, and six patients had C-shaped tears. None of the patients had healing problems or avascular necrosis. The mean Constant-Murley shoulder score was 85.4 (range 67 to 100). All the patients were satisfied with the results of surgical treatment. CONCLUSION: The integrity of the rotator cuff must be checked after reduction and fixation of proximal humerus fractures and, when present, the tears should be repaired simultaneously either primarily or with suture anchors. Simultaneous repair of rotator cuff tears does not negatively affect functional outcomes.

Complications encountered in proximal humerus fractures treated with locking plate fixation.

OBJECTIVES: We evaluated the complications encountered following locking plate fixation of proximal humerus fractures. METHODS: The study included 103 patients (70 females, 33 males; mean age 62 years; range 21 to 90 years) who were treated with open reduction and locking plate fixation for proximal humerus fractures between September 2005 and April 2009. Fixation was performed using the PHILOS locking plate in 93 patients, and S3 humerus plate in 10 patients. Postoperatively, a shoulder-arm sling was applied for six weeks and a standard rehabilitation program was used in all the patients. Intraoperative, acute postoperative, and late postoperative complications were assessed on radiographs. Varus inclination was defined as less than 120 degrees of the inclination angle on immediate postoperative radiographs, and varus displacement as postoperative increases in the varus angle. The mean follow-up period was 19 months (range 2 weeks to 43 months). RESULTS: Complications were seen in 10 patients (9.7%; mean age 67 years). The PHILOS plate was used in nine patients and S3 plate was used in one patient. Five patients (4.9%) had varus inclination with a mean inclination angle of 112.6 degrees (range 105 degrees to 118 degrees), four patients (3.9%) developed varus displacement with a mean inclination angle of 102.5 degrees (range 95 degrees to 110 degrees), and intra-articular screw penetration was seen in five patients (4.9%). The remaining complications were fixation failure (n=1, 1%), implant fracture (n=1), and deep infection (n=1). Screw penetration exceeded 3 mm in three patients, requiring revision surgery. The mean ages of patients with varus inclination, varus displacement, and screw penetration were 76.6, 74.4, and 71 years, respectively. Three patients with varus inclination (60%) developed varus displacement. Screw penetration was observed in three patients (60%) with varus inclination, and in all patients with varus displacement. The mean Constant-Murley shoulder score was 67.8 (range 50 to 90) in patients who developed a complication. CONCLUSION: Our findings show that locking plate and screw systems represent a significant treatment option in the treatment of comminuted and displaced humerus fractures, with low complication rates. Accurate indication, protection of the head's inclination angle through appropriate surgical approach and proper technique, and fine calculation of screw length are essential for successful functional results.

[Surgical treatment of elbow dislocations accompanied by coronoid fractures]. / Koronoid kiriklarinin eslik ettigi dirsek çikiklarinda cerrahi yaklasim.

OBJECTIVES: We evaluated the results of surgical treatment for elbow dislocations accompanied by Regan-Morrey type 2-3 coronoid fractures. METHODS: Eight patients (6 males, 2 females; mean age 44 years; range 23 to 76 years) underwent surgical treatment for elbow dislocations accompanied by a coronoid fracture. Three patients had Regan-Morrey type 2, five patients had type 3 coronoid fractures. Accompanying injuries were Mason-Johnston type 4 radial head fractures (n=6), olecranon fractures (n=4), lateral humeral condyle fracture (n=1), and lateral (n=5) or medial (n=2) collateral ligament ruptures. Coronoid fractures were fixed with a plate, screw, or a cerclage wire in all the patients except for one patient who underwent coronoid excision. For radial head fractures, plate or screw and K-wire fixation was performed in two patients and radial head prosthesis was used in four patients. Olecranon fractures were fixed with a plate or AO tension band. Functional results were assessed using the Mayo elbow performance score. The mean follow-up period was 22.6 months (range 1 to 65.5 months). RESULTS: Union was achieved in all the patients. At the latest assessments, the mean Mayo elbow performance score was 84.3 (range 50 to 100). All the patients expressed satisfaction with surgical treatment except for one patient who underwent coronoid excision. All the fixation materials used for olecranon fractures were removed after union due to implant-associated pain. Ulnar nerve transposition was required in two patients with fractures involving the anteromedial facet of the coronoid process. Two patients developed heterotopic ossification that did not affect the range of motion of the elbow. CONCLUSION: Surgical treatment of elbow dislocations associated with Regan-Morrey type 2-3 coronoid fractures enables a concentric reduction of the elbow, stability, and early motion.

[Early results of autologous mononuclear bone marrow cell implantation in nontraumatic avascular necrosis of the femoral head]. / Travmaya bagli olmayan femur basi osteonekrozunda otolog konsantre mononükleer kemik iligi hücre naklinin erken dönem sonuçlari.

OBJECTIVES: We evaluated early clinical and radiologic results of core decompression combined with autologous mononuclear bone marrow cell implantation for early stage nontraumatic avascular necrosis of the femoral head. METHODS: The study included nine patients (1 female, 8 males, mean age 46.5 years; range 33 to 59 years) with stage I-II nontraumatic avascular necrosis of the femoral head, according to the Steinberg classification. Bone marrow-derived CD34 cells were injected through a core decompression channel into the femoral head. Clinical assessment included a visual analog scale (VAS), Harris hip score, and the WOMAC Osteoarthritis Index. Radiologically, femoral head collapse, narrowing of the coxofemoral joint space, and the size of the osteonecrotic area were assessed. The mean follow-up was 27.2 months (range 24 to 38 months). RESULTS: Pre- and postoperative (24th month) evaluations showed that the mean VAS score and the WOMAC Osteoarthritis Index decreased from 3.4+/-0.4 to 1.2+/-0.6, and from 33+/-3 to 11+/-6, respectively, with an increase in the Harris hip score (from 54 to 92). Preoperatively, two patients were Steinberg I-B, four were I-C, and three were II-A. Finally, all the patients were stage 0 except for one patient who regressed to I-A. None of the patients exhibited femoral head collapse or narrowing of the coxofemoral joint space. CONCLUSION: Autologous mononuclear bone marrow cell implantation relieves articular pain, prevents the progression of osteonecrosis, and hence subchondral fractures. Therefore, it may be treatment of choice particularly in stage I-II avascular necrosis of the femoral head.

[The results of internal fixation of proximal humeral fractures with the PHILOS locking plate]. / Proksimal humerus kiriklarinda kilitli plak PHILOS ile internal tespit sonuçlari.

OBJECTIVES: Proximal and diaphyseal humeral fractures are common especially in the elderly, presenting as a challenging problem due to their high complication rates following surgical treatment. In this prospective study, we evaluated the results of patients treated with the PHILOS (Proximal Humeral Internal Locking System) locking plate, a new technique recently developed by the AO/ASIF. METHODS: Forty-one patients who were treated with the PHILOS plate for proximal humeral fractures were evaluated in two age groups. Group A included 24 patients (12 males, 12 females; mean age 47 years; range 24 to 64 years) younger than 65 years, and group B involved 17 patients (4 males, 13 females; mean age 78 years; range 67 to 90 years) at or above 65 years. Radiographically, all fractures were classified according to the AO/ASIF system. Surgery was performed with the deltopectoral approach in 10 and two patients, and with a deltoid split in 14 and 15 patients in group A and B, respectively. Functional and radiographic results were evaluated after a mean follow-up of 15 months (range 6 to 28 months). RESULTS: The mean Constant scores were 95.0 (range 74 to 100) and 92.8 (range 72 to 100) in group A and B, respectively (p>0.05). After six months of surgery, Constant scores and functional outcomes were similar in patients operated on with the deltopectoral approach or deltoid split. There was neither nonunion nor implant failure. Complications included intra-articular screw penetration (n=1), displacement of the greater tuberculum (n=1) with oblique placement of the plate (n=1), insufficient reduction (n=4), and varus displacement of the humeral head (n=3). No avascular necrosis was seen. CONCLUSION: Locking plate system is superior over other means of fixation methods, particularly in osteoporotic fractures, because it allows early rehabilitation and does not result in implant failure.

[Treatment of stiff-knee gait by distal rectus femoris transfer]. / Tutuk diz yürüyüsünde distal rektus femoris transferi ve klinik sonuçlarimiz.

OBJECTIVES: We evaluated the preliminary results of distal rectus femoris transfer in patients with stiff-knee gait due to cerebral palsy. METHODS: Eight knees of four patients who had stiff-knee gait due to cerebral palsy were treated by distal rectus femoris transfer. All the patients were females with a mean age of 11 years (range 9.5 to 12 years). Preoperatively and postoperatively, lower extremity examinations, the Ely test, and clinical gait analyses were performed. Satisfaction levels of the patients and their families were questioned. The mean follow-up was 17.5 months (range 3 to 23 months). RESULTS: None of the patients manifested flexion contracture of their hips and knees postoperatively. The Ely test was negative in all patients. There were no clinical signs of stiff-knee gait. All the patients and their families but one expressed their satisfaction with clinical and functional results. CONCLUSION: Our clinical results suggest that distal rectus femoris transfer is effective in the treatment of stiff-knee gait due to cerebral palsy.