Tourniquet use in orthopedic surgery: a descriptive survey study among Turkish orthopedic surgeons and residents in Istanbul.

OBJECTIVE: The aim of this study was to investigate and interpret the trends in tourniquet use and the accuracy of knowledge among Turkish orthopedic physicians through face-to-face survey. METHODS: Turkish orthopedic physicians actively practicing operative orthopedics were questioned in a 12 question face-to-face survey. Personal information of physicians, preferred cuff pressure (CP) and tourniquet inflation time (TIT) and the source of the information for these preferences were questioned. Answers gathered were analyzed statistically. RESULTS: The survey was completed by 211 orthopedic physicians. Mean preferred CP and TIT was 247.1 mmHg and 108.6 minutes, respectively, in the upper limb (UL) and 345.02 mmHg and 122.4 minutes, respectively, in the lower limb (LL). A statistically significant correlation was found between the amount of pressure preferred in the LL and the years of practice; longer the years in practice, higher the amount of pressure preferred (r=0.144, p=0.04). Tourniquets were used for a maximum period of 120 minutes for the UL by 95.7% of participants and for the LL by 84.8%. CONCLUSION: The amount of CP used by the orthopedic physicians surveyed is inconsistent with the literature with frequent use of CP higher than those scientifically recommended. The outcomes of the survey should be cautionary for orthopedic physicians to review the current utilization and replace personal teachings and experience-based methods with evidence-based best practices for tourniquet application.

Perioperative versus postoperative measurement of Taylor Spatial Frame mounting parameters.

OBJECTIVE: The aim of this study was to determine the differences, if any, between application parameters for the Taylor Spatial Frame (TSF) system obtained during surgery under fluoroscopy and after surgery from digital radiography. METHODS: This retrospective study included 17 extremities of 15 patients (8 male, 7 female; mean age: 21.9 years, range: 10 to 55 years) who underwent TSF after deformity and fracture. Application parameters measured by fluoroscopy at the end of surgery after mounting the fixator were compared with parameters obtained from anteroposterior and lateral digital radiographs taken 1 day after surgery. RESULTS: Fixator was applied to the femur in 8 patients, tibia in 6 and radius in 3. Mean time to removal of the frame was 3.5 (range: 3 to 7) months. Mean perioperative anteroposterior, lateral and axial frame offsets of patients were 9.1 (range: 3 to 20) mm, 18.1 (range: 5 to 37) mm and 95.3 (range: 25 to 155) mm, respectively. Mean postoperative anteroposterior, lateral and axial frame offset radiographs were 11.8 (range: 2 to 30) mm, 18 (range: 6 to 47) mm and 109.5 (range: 28 to 195) mm, respectively. There was no statistically significant difference between the groups (p>0.05). CONCLUSION: While measurements taken during operation may lengthen the duration in the operation room, fluoroscopy may provide better images and is easier to perform than digital radiography. On the other hand, there is no difference between measurements taken during perioperative fluoroscopy and postoperative digital radiography.

Isolated subtalar fusion for neglected painful intra-articular calcaneal fractures.

OBJECTIVE: The objective of this study was to evaluate the radiological and clinical outcomes of treatment of subtalar arthrodesis in patients developing talocalcaneal arthrosis secondary to intra-articular calcaneal fractures. METHODS: The study included 20 patients (21 feet) who underwent subtalar arthrodesis due to symptomatic subtalar arthrosis following conservative treatment for intra-articular calcaneal fracture between 2005 and 2011. Autograft or allograft was used in 11 patients. Patients were evaluated clinically using the American Orthopedic Foot and Ankle Society (AOFAS) ankle hindfoot score. Hindfoot alignment, quality of subtalar fusion and arthritis occurring in other joints were used for the radiological evaluations. RESULTS: Mean duration of follow-up was 43 (range: 21 to 83) months. Mean preoperative AOFAS score was 61.7 (range: 40 to 67) and mean postoperative AOFAS score was 84.2 (range: 65 to 94). The difference between scores was statistically significant (p=0.001). Six patients had excellent, 8 good and 6 fair results. Complete fusion was achieved in 19 patients (20 feet). In 2 patients, arthritic changes were radiologically observed in the midtarsal joints. These changes were not symptomatic. There were no statistically significant differences between pre- and postoperative radiological measurements. No patients experienced malunion. CONCLUSION: While subtalar arthrodesis appears to provide radiological and clinical benefits, it may cause moderate and asymptomatic osteoarthritis in the midtarsal joints.

Fixed-angle volar plates in corrective osteotomies of malunions of dorsally angulated distal radius fractures.

OBJECTIVE: The aim of the study was to evaluate the radiological and functional outcomes of corrective osteotomy of malunited, dorsally tilted distal radius fractures, using fixed-angle volar plates. METHODS: We conducted a prospective study on 17 (10 male, 7 female; mean age: 41 years; range: 18 to 67 years) consecutive patients who were referred to our institution for treatment of a symptomatic malunion of the distal radius. The mean time from fracture to osteotomy was 4.4 (range: 2 to 7) months. Eight (45%) of the malunited fractures were on the dominant wrist. All patients were treated with an opening wedge osteotomy with a fixed-angle volar plate and cancellous bone grafting. Radiological measurements were performed pre- and postoperatively, including ulnar variance, radial inclination, and radial tilt. The degree of degenerative changes in the radiocarpal joint was assessed according to the criteria of Knirk and Jupiter. Forearm pronation/ supination and wrist flexion/extension range of motion and grip strength were measured and compared with the opposite healthy side. Functional evaluation was performed with a Turkish version of the Q-DASH (Disabilities of the Arm, Shoulder and Hand Quick form) questionnaire. RESULTS: Mean follow-up evaluation was made at an average of 20.4 (range: 12 to 38) months. All osteotomies healed radiologically at mean time of 12.2 (range: 12 to 16) weeks. There was a significant improvement in the anatomical and functional parameters (p<0.05). The mean tilt of the radius improved from -27.4° of extension to 3.4° of extension and the mean radial inclination improved from 18.4° to 22.5°. The mean ulnar variance improved from 12.1 mm to <1 mm. Wrist flexion/extension range of motion improved from 100.8° to 144° and forearm range of rotation increased from 118° to 174.6°. Radial and ulnar deviation averaged from 22° to 27.3° postoperatively. According to the criteria of Knirk and Jupiter, 3 patients (17%) had Stage 2 degenerative arthritis. The average Q-DASH score improved from 26.5 to 5.7 and grip strength increased from 59.7% (17.5 kg) to 83.2% (24.4 kg) of the opposite side strength. CONCLUSION: Fixed-angle volar plates provide a stable fixation after corrective osteotomies of the distal radius and might be a safer alternative to conventional fixation methods.

Comparative evaluation of radiographic and functional outcomes in the surgical treatment of scaphoid non-unions.

OBJECTIVE: The aim of our study was to evaluate the correlation between the radiological signs of union and functional outcomes in patients with surgically treated scaphoid non-unions. METHODS: In our study, we evaluated 13 patients who underwent surgery at our clinic for complaints resulting from an unhealed scaphoid fracture. Of the scaphoid non-unions, 9 were on the scaphoid body and 4 were on the proximal pole. According to Slade's classification system, there were two Grade 4, eight Grade 5, and three Grade 6 fractures. The patients were all male with a mean age of 31, with 25 months of mean time between the onset of trauma and surgery. All fractures were treated through open reduction with autogenous bone grafting (cancellous in 4 cases; corticocancellous in 9 cases) and fixation with compression screws. Bone morphology and carpal alignment were assessed through radiography, using the scaphoid index and scapholunate angle measurements, respectively. Range of motion and grip strength measurements together with the modified Mayo wrist scores were used in the assessment of wrist functionality. RESULTS: Average duration of follow-up was 16 months. In 10 patients, radiological union was attained in a mean time of 12.4 weeks following the operation. There was a substantial improvement in grip strength and range of motion values after surgery. The preoperative mean modified Mayo wrist score of 41.5 improved to 79.2 postoperatively. Accordingly, 4 patients had perfect, 2 had good, 5 had fair and 2 had poor results. The surgical treatment allowed the preoperative mean scapholunate angle of 45.8° and the preoperative mean scaphoid index of 0.69 to be reduced to 32° and 0.6, respectively. The humpback deformity present in 11 patients before the surgery was restored in 10 patients by reconstruction of the scaphoid bone length. Abnormal carpal alignment was restored in 4 of these patients. No statistically significant correlation was found between the functional results and the surgically attained structural restorations and union process. CONCLUSION: The surgical treatment of scaphoid fracture non-unions can correct bone morphology and resolve alignment problems but might not be sufficient for the improvement of functional results.

[Asymmetric bilateral traumatic dislocation of the hip joint: a case report]. / Asimetrik iki tarafli travmatik kalça çikigi: Olgu sunumu.

Bilateral traumatic dislocation of the hip is a rare condition. Simultaneous asymmetric traumatic dislocation of the hip, one hip anterior and the other posterior, is even more unusual. This article reports a 21-year-old male patient with asymmetric bilateral dislocation of the hip joint, injured due to a landslide during a canal excavation. The patient was treated conservatively and evaluated according to Thompson and Epstein clinical and radiographic criteria after a follow-up period of 10 years and six months. The clinical result was perfect and radiographical result was good. We determined that our case had occurred as a result of a mechanism that has not been previously published in the literature and evaluated it from this point of view.

[The relationship between anterior knee pain occurring after tibial intramedullary nailing and the localization of the nail in the proximal tibia]. / Tibia kiriklarinin intramedüller çivi ile tedavisi sonrasi görülen diz önü agrisinin proksimal tibiadaki çivi yerlesimi ile iliskisi.

OBJECTIVES: We investigated the relationship between the development of postoperative anterior knee pain and the location of the nail in the proximal tibia in patients treated with locked intramedullary nailing for tibial diaphyseal fractures. METHODS: Thirty patients were selected among those who underwent locked intramedullary nailing for tibial diaphyseal fractures, with exclusion of all other factors that might be associated with postoperative anterior knee pain. In all the patients, intramedullary nailing was performed using the transtendinous approach and both proximal and distal locking. The patients were evaluated in two groups: 10 patients (3 women, 7 men; mean age 38 + or - 14 years) had anterior knee pain, whereas 20 patients (5 women, 15 men; mean age 35 + or - 12 years) did not. The distances from the nail to the tibial plateau and anterior tibial cortex were measured on the lateral x-rays after a mean follow-up of 56.6 months and 45.2 months in patients with and without anterior knee pain, respectively. RESULTS: The two groups were similar with respect to gender and follow-up period (p>0.05). The mean distances from the nail to the tibial plateau and anterior tibial cortex were -11.5 + or - 7.9 mm and 3.7 + or - 5.4 mm, respectively, in patients with anterior knee pain. The corresponding distances were -8.8 + or - 7.3 mm and 6.5 + or - 4.7 mm in patients without knee pain. Neither of the distances showed a significant difference between the two groups (p>0.05). CONCLUSION: Our findings suggest that the distances from the nail to the tibial plateau and anterior tibial cortex do not have any role in the development of postoperative anterior knee pain.

[Congenital pseudarthrosis of the clavicle in two siblings]. / Iki kardeste dogustan klavikula psödoartrozu.

Congenital pseudarthrosis of the clavicle is a rare disorder of unknown etiology. Among nearly 200 cases hitherto reported, only a few cases have familial coexistence, and none are first-degree relatives. A nine-year old girl had complaints of weakness in the right arm and swelling in the right shoulder. On physical examination, a mass-like lesion in the right clavicle, abnormal clavicular movement, and asymmetric shoulders were noted. The range of motion of the shoulder was in normal range on both sides. A plain radiogram showed a defect in the diaphysis of the right clavicle and computed tomography showed discontinuity of the right clavicle. Similar clinical and radiologic findings were also detected in her younger sister who was three years old. None had a history of trauma, difficult delivery, or natal complication, any abnormal findings related to the musculoskeletal system, any abnormality in routine laboratory test results and genetic analysis. The diagnosis was made as congenital pseudarthrosis of the clavicle in both siblings. Since they had normal range of joint movements without pain, they were scheduled for clinical follow-up. To our knowledge, these two siblings are the first to be reported in the literature for having congenital pseudarthrosis of the clavicle.

[Plate fixation of closed femoral shaft fractures in adolescents]. / Adölesan kapali femur cisim kiriklarinin tedavisinde plak ve vida ile osteosentez.

OBJECTIVES: This study was designed to evaluate the results, advantages, and disadvantages of plate fixation of closed femoral shaft fractures in adolescents between the ages of 11 and 15 years. METHODS: The study included 35 adolescents (26 males, 9 females; mean age 13.4 years) who were treated by plate fixation for closed femoral shaft fractures and had an adequate follow-up. The fractures were bilateral in two patients, on the left in 17 patients (48%), and on the right in 16 patients (45%). Traffic accidents were the most frequent etiology (57%). Nineteen patients presented with head injuries and/or multiple fractures. The mean follow-up was 34.9 months (range 22 to 156 months). RESULTS: All fractures healed in a mean of 10 weeks (range 6 to 16 weeks). No plate break or refractures occurred. Two patients had a loss of 20 degrees in knee flexion. Atrophy of the quadriceps muscle was observed in nine patients. Evaluations with the use of scanogram, orthorontgenogram, plain radiographs, and clinical examination showed an average overgrowth of 1.2 cm (range 0.4 to 1.6 cm). CONCLUSION: Despite some disadvantages, plate fixation seems to be an alternative method in the treatment of adolescent femoral fractures, enabling an anatomical reduction and stable internal fixation.