A novel model of locking plate and locking spongious screw: a biomechanical in vitro comparison study with classical locking plate.

BACKGROUND: Locking plates are commonly used for the fixation of comminuted, periprosthetic and osteoporotic bone fractures. These plates are secured to the bone with screws, creating a stable connection with fixed angle between the plate and the screws. In this biomechanical in vitro study, our aim is to evaluate and compare the novel locking plate-locking spongious screw model with FDA approved classical locking plate. METHODS: Sawbone PCF-15 osteoporotic bone model was utilized to simulate osteoporotic bone conditions. Two screws were used to attach both the classical locking plate and the novel locking plate-locking spongious screw model to these bone models. The attachment strength of the screws to the bone blocks was measured by pull-out tests. RESULTS: Novel locking plate-locking spongious screw model exhibited an 84.38% stronger attachment to the osteoporotic bone model compared to the current locking plate model. CONCLUSIONS: In conclusion, one of the important problems in the locking plates which is the high Pull-out risk of the locking spongious screws can been resolved with our proposed new model and has a chance of having a better purchase especially in osteoporotic bones.

Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting: Results of 7.6-year follow-up.

OBJECTIVES: The aim of this study was to determine long term follow up of the patients who had femoral head osteonecrosis and had been treated with free vascularized fibular grafting. PATIENTS AND METHODS: We retrospectively reviewed 28 hips of 21 patients who had undergone free vascularized fibular grafting for the treatment of osteonecrosis of femoral head. There were 16 male and 5 female patients. The mean age of the patients at the time of surgery was 30.7 years (between 15 and 53 years). The mean follow-up time was 7.6 years (between 5 years and 9.2 years). RESULTS: During follow-up, one patient died because of leukemia, and one patient was lost. The remaining 26 hips of 19 patients were evaluated. According to the Ficat classification, at the time of surgery, 17 hips were in grade 2 and 9 hips were in grade 3. The post-operative Harris hip scores in grade II disease were excellent in 12 patients, good in 3 patients, and fair in 1 patient. In grade III disease, 1 patient was excellent, 5 patients were good, and 1 patient was fair. There was a significant increase in HHS scores (61 ± 9.7 vs 84 ± 17.8, p < 0.001). CONCLUSION: Free vascularized fibular grafting yields extremely good results, particularly in pre-collapse stages of disease in young patients. The operation time does not mark increased if the surgical team is "familiar" with the procedure, and the residual fibular defect of the donor site does not impair the functions of daily living. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Surgical Treatment of Lateral Malleolar Fractures Using the Compression Cerclage System.

Background Lateral malleolar fractures (Weber type B or OTA 44-B) account for 60% of all ankle fractures. To achieve anatomic restoration, surgical stabilization provides better results than conservative treatment. Various fixation methods are available to treat these fractures; however, the best method is still unknown. Our objectives were to present a new, useful, and efficient surgical technique for stabilizing lateral malleolar fractures and to analyze the outcomes of patients treated with the compression cerclage system. Methods The surgical technique consists of a Kirschner wire that is passed percutaneously and perpendicular to the fracture line, and a cerclage wire that is passed in a semi-circular fashion over the ends of the Kirschner wire on the lateral side of the bone, leaving loops on each side to allow bilateral compression while twisting both wires. We retrospectively evaluated patients treated with this technique, with or without additional fractures. Follow-up of <24 months and bilateral ankle fractures were the exclusion criteria. Fractures were examined clinically and radiologically in comparison to the uninjured side and were rated according to the criteria reported by McLennon and Ungersma. Olerud and Molander ankle score was used to evaluate functional outcome. Results At the final follow-up, 15 out of 21 patients (9 women and 6 men; mean age, 48.2 years [range, 19-78 years]) were evaluated. The mean follow-up was 5.16 years (28-129 months). Five patients had an isolated lateral malleolar fracture; eight had lateral and medial malleolar fractures; and two had trimalleolar fractures. At the final follow-up, 11 patients were rated good functionally and four were fair, and all patients were rated good radiographically according to the criteria by McLennon and Ungersma. Mean Olerud and Molander ankle score was 93.3 (range, 80-100). Conclusions The compression cerclage system provides good functional and radiological outcomes in patients with lateral malleolus fractures. This method is useful, safe, and efficient with minimum hardware. It can be applied through limited soft-tissue stripping, which is especially important in patients with a high risk for wound complications.

Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting: results of 7.6-year follow-up.

OBJECTIVE: The aim of this study was to determine long-term follow-up results of patients with femoral head osteonecrosis who were treated with free vascularized fibular grafting (FVFG). METHODS: The results of 28 hips of 21 patients (16 male, 5 female) who underwent FVFG for treatment of osteonecrosis of the femoral head were retrospectively reviewed. Mean age of patients at time of surgery was 30.7 years (range: 15-53 years). Mean follow-up duration was 7.6 years (range: 5-9.2 years). RESULTS: During follow-up, 1 patient died because of leukemia, and 1 patient was lost. The remaining 26 hips of 19 patients were evaluated. According to Ficat classification, at time of surgery, 17 hips were grade II, and 9 hips were grade III, 3 hips underwent total hip arthroplasty. Postoperative Harris Hip Score (HHS) in grade II disease was excellent in 12 patients, good in 3 patients, and fair in 1 patient. In grade III disease, 1 patient was excellent, 5 patients were good, and 1 patient was fair. There was a significant increase in HHS scores from preoperatively to postoperatively (61±9.7 vs 84±17.8, p<0.001). CONCLUSION: FVFG yields extremely good results, particularly in pre-collapse stages of the disease in young patients. The operation time does not markedly increase if the surgical team is knowledgeable of the procedure and the residual fibular defect of the donor site does not impair functions of daily living.

Distraction lengthening of the proximal phalanx in distal thumb amputations.

OBJECTIVE: Thumb amputation is a major cause of hand dysfunction, and the treatment for distal thumb amputations remains controversial. Although finger reconstruction methods using distraction lengthening are known to restore finger length and function, we found no reports in the literature regarding phalangeal lengthening in thumb amputations. We aimed to evaluate proximal phalangeal lengthening in thumb amputations at or near the interphalangeal (IP) joint. METHODS: We retrospectively evaluated patients who had undergone distraction lengthening of the proximal phalanx of the thumb. All patients underwent osteotomy, either during the initial procedure or as a second-stage procedure. Distraction began 10 days after osteotomy with the use of an external fixator that remained in place until ossification of the gap occurred without bone grafting. Patients were evaluated using the QuickDASH score. RESULTS: Fourteen patients with a mean age of 27 years and a mean follow-up period of 7 years were enrolled. The mean phalangeal lengthening achieved was 20 mm. Ossification occurred at all distraction sites, and the fixators were maintained for a mean of 85 days. The mean healing index was 42.5 days/cm. All 14 patients achieved the desired amount of phalangeal lengthening without major complications such as nonunion, premature union, or gross infection. CONCLUSION: For reconstruction in cases of distal thumb amputations, distraction lengthening of the proximal phalanx can be used to improve absolute length, web space, and grip distance. The technique is safe and effective, improves functionality/cosmesis, and offers a low complication risk.

Acute emergency tibialization of the fibula: reconstruction of a massive tibial defect in a type IIIC open fracture.

Gustilo type IIIC open fractures of the tibia are high-energy injuries necessitating long treatment periods and usually multiple surgical procedures and eventually resulting in high morbidity rates and even amputations. We present here a case involving a type IIIC open tibial fracture with massive loss of the entire tibial diaphysis, which we treated by performing acute tibialization of the fibula after revascularization of the posterior tibial artery in a single-stage emergency operation.

Trigger finger at the carpal tunnel level: three case reports.

Although trigger finger occurs mostly due to a problem at the A1 pulley various other causes have also been reported. We present three patients with different tumors at the carpal tunnel as a cause of triggering. All patients were treated with local excision.

Functional results of limb salvage in below-knee type III C open fractures or traumatic amputations.

This study presents the surgical and functional outcomes of below-knee total leg amputation and Gustilo type III C open fracture cases that were considered appropriate for salvage treatment according to a more proactive approach, despite being candidates for amputation according to the current scoring systems. Nineteen patients (21 legs) underwent replantation-revascularization surgery. At least Chen Grade II functional level was the aim. A limb salvage operation was performed in 21 legs in 19 patients (18 male, 1 female). The mean age was 28.5 years (range: 11 to 42 years). Six legs in four patients presented with total amputation, and 15 legs in 15 patients had Gustilo Type III C open fractures. A successful replantation/revascularization was performed in 20 legs, with a Chen Grade I and Grade II functional outcome in 3 and 17 legs, respectively. None of these patients were eligible for salvage operation according to currently used scoring systems. Limb-preserving surgery performed upon the assessment of local and general conditions of the patients with traumatic below-knee amputations or Gustilo Type III C open fractures seems to be a viable therapeutic option that can serve to achieve Chen Grade II functional level in most patients.

Lengthening of a thumb distal phalanx replanted to its metacarpus because of loss of the proximal phalanx: case report.

We report a successful thumb replantation by resecting the remnants of the crushed proximal phalanx and uniting the distal phalanx with the thumb metacarpal. The procedure resulted in extreme shortening, which we managed by distraction lengthening and deepening of the first webspace.

Massive subcutaneous emphysema and pneumomediastineum after finger subtotal amputation with barotrauma.

BACKGROUND: Advancement of pressurized air through subcutaneous tissue after barotraumas involving skin laceration has been documented in the literature. The type and anatomic location of injury, amount of pressure, and time elapsed all play a role in determining the destination of the air advancing through tissues. OBJECTIVES: To report a case demonstrating the vascular system as the anatomic pathway for subcutaneous pressurized air resulting from an industrial accident. CASE REPORT: We present the case of a 28-year-old laborer wounded by an air valve blast. An enormous accumulation of air was released through a subtotal fingertip amputation. The clinical appearance of massive subcutaneous emphysema around the upper extremity, neck, and chest suggested chest trauma to the clinicians, despite the absence of signs of respiratory distress. X-ray studies revealed pneumomediastinum. After confirmation that the respiratory system was undamaged, microsurgical repair of the injured finger was performed. Resolution of subcutaneous emphysema and pneumomediastinum was complete at the end of follow-up. CONCLUSION: Compressed air injuries constitute a well-known form of industrial accident. Although most result in localized subcutaneous emphysema, the risk of pneumomediastinum should not be overlooked due to the anatomic structure of the vascular system. The clinician should consider the pressure of compressed air, and must be alert for potential complications.

[Lengthening of the phalanges by callus distraction in traumatic amputations of the fingers]. / El parmak travmatik amputasyonlarinda kallus distraksiyonu yöntemi ile falangeal uzatma.

OBJECTIVES: We evaluated the results of lengthening of the phalanges by callus distraction in traumatic amputations of the fingers. METHODS: We treated traumatic amputations of 16 fingers of 13 male patients (mean age 27.7 years; range 12 to 43 years) by callotasis of the phalanges. Callus distraction was performed with a rate of 1 mm/day using a unilateral dynamic external fixation device. The mean follow-up period was 42 months (range 12 to 80 months). RESULTS: The mean lengthening was 24 mm (range 18 to 26 mm) and 21 mm (range 18 to 26 mm) for the thumbs and the other fingers, respectively. The achieved thumb length provided adequate depth and width of the first web space and enabled functional improvement in the ability of gripping, and pulp-to-pulp and pulp-to-side pinching. In the absence of flexor pollicis longus, the mean strength of the thumbs was 7 kg (range 5 to 9 kg), amounting to 65% of the normal side. Lengthening of the other fingers resulted in improved functioning of the hand. The mean healing index (number of months per centimetre of lengthening) was 1.7 months/cm (range 1.6 to 2.1 months/cm) and 1.6 months/cm (range 1.4 to 1.9 months/cm) in the thumbs and the other fingers, respectively. Pin tract infections were observed in four phalanges. CONCLUSION: Callotasis of the proximal phalanx of the thumb is an effective reconstruction method to compensate for the loss of distal phalanx and to alleviate functional problems due to shortness. It may also be applied to the phalanges of the other fingers in patients who do not accept ray resection with or without transposition.

Role of side branches in determining suitable arterial segments for anastomosis in avulsion injuries: experimental studies.

The role of side branches, when the parent arterial trunk is stretched, with emphasis on preventing the effects of avulsion injury, was investigated in an experimental model. In ten New Zealand rabbits, the femoral arteries were isolated with and without side branches in the left and right legs, respectively, and controlled longitudinal traction was applied. The elongation of the arteries just before avulsion rupture at each side, with and without side branches, was compared, by measuring the initial and final length from the inguinal ligament to the mid-point of the distance between the inguinal ligament and the saphenous bifurcation. Side branches were observed to be tethered in a way that resisted elongation of the trunk artery. Arteries without side branches in the right legs elongated more, as they lacked the fixating and protective support provided by the side branches. Comparison of the two legs, with and without side branches, showed an average of 50 percent more arterial elongation, resulting in severe injury to the arteries without side branches. In the light of these results, the authors suggest performing microsurgical arterial anastomosis after resection past a minimum of two unruptured branch points of the avulsed part, in order to obtain a safer arterial segment for a better patency rate.

Lengthening of replanted or revascularized lower limbs: is length discrepancy a contraindication for limb salvage?

Some replantation cases require substantial bone shortening for primary closure. Leg-length discrepancy can be restored by lengthening of the replanted or revascularized extremities. Between 1991 and 2000, four patients with four total and two subtotal below-knee amputations had replantation or revascularization for their severely damaged extremities. All of them had extensive debridement, vascular repair, bone shortening and nerve repair for sensibility of their soles. One of the replanted extremities failed and had to undergo below-knee amputation because of sepsis. No other infection or vascular complications were encountered following the replantations or revascularizations. After bony consolidation, four legs were lengthened; for elimination of length discrepancy in three cases, and for obtaining balanced body proportion in one case in which the other leg was also amputated. In all procedures, a unilateral dynamic axial external fixator was used. The lengthening was performed from the proximal tibial metaphysis, with a subperiosteal osteotomy. Evaluation of injury according to the Mangled Extremity Severity Score (MESS) would encourage the surgeon to avoid salvage surgery with a shortened extremity, because of the required debridement of soft tissue and bone. These authors think the amount of limb shortening is not a major criterion in evaluating a traumatic total or subtotal below-knee amputation for salvage replantation or revascularization. A knee that has stable joint motion and the possibility of preservation of sensibility of the sole broadens the scope of indications for limb salvage, even with deliberate shortening that can be restored by lengthening; length discrepancy is not a contraindication for limb salvage.

A modified method of microvascular autogenous interposition vein grafting for vascular reconstruction.

A modified technique of vein grafting for vascular reconstruction that facilitates surgical procedures by preventing size, diameter, and length discrepancies as well as twisting, is presented. The distal end of the harvested vein graft is ligated, and the graft is inflated with heparinzed saline. The determination of the small side branches makes ligation easier. Gentle hydrostatic dilation relieves spasm, straightens the vein, and ligation of the proximal end is then performed under tension. As the vein inflated with heparinzed saline achieves maximum size, diameter, and length without torsion, the sausage-like graft can easily be interposed in tunnels, passages, or soft tissues between recipient vessel gaps. As the graft is under adequate tension, it is easy to determine its appropriate length, size, and diameter. Suturing is carried out using double approximating clamps. The graft will not twist or kink, as it is anastomosed under tension. The clamps are left in place until completion of the distal and proximal anastomoses. The distal clamp is released first. With this simple modification, most of the technical difficulties, such as length, size, and diameter discrepancies, and twisting and torsion of the graft, can be eliminated. The risk of failure due to vascular thrombosis at the anastomotic sites is lowered, as the vein graft is filled with heparinzed saline, and no blood flow is permitted during the reconstruction. The surgeon also saves time with this easy, simple, and feasible method.