Intraoperative fluoroscopic safety assessment of femoral head implants with 3-dimensional risk parameters to minimize cut-out.

OBJECTIVE: This study aimed to introduce a method to extract the 3-dimensional spatial position of the femoral head implant from 2-dimensional fluoroscopic projections, allowing surgeons to assess fixation much more accurately and prevent cut-out complications in proximal femoral nailing. METHODS: To define a safety region for the tip in the femoral head, a novel 3-dimensional distance-based risk parameter called TSD3D was introduced. An intersection algorithm was developed that solely takes the fluoroscopic anteroposterior and lateral distances to reveal the 3-dimensional location of the screw or Kirschner wire tip, enabling the utilization of the 3-dimensional parameter. Orthogonal per- spectives of 6 femur proximal bone substitutes with randomly inserted Kirschner wires were imaged under fluoroscopy. The developed algorithm was used to calculate the implant tip location in 3-dimensional from 2-dimensional images for each case. Algorithm accuracy was validated with the computed tomography-obtained 3-dimensional models of the same femur substitutes. RESULTS: The newly introduced risk parameter successfully visualizes 3-dimensional safety regions. Utilizing the 2-dimensional fluoro- scopic distances as inputs to the algorithm, the 3-dimensional position of the implanted Kirschner wire tip is calculated with a maximum of 9.8% error for a single Cartesian-coordinate measurement comparison. CONCLUSION: By incorporating the newly introduced 3-dimensional risk parameter, surgeons can more precisely evaluate the position of the implant and avoid cut-out complications, instead of relying solely on misleading 2-dimensional fluoroscopic projections of the femoral head.

A new checklist surgical hand scrub to replace time-based methods - A pixel intensity analysis.

BACKGROUND: Hand scrubbing is an absolute precaution to avoid surgical site infections. World Health Organization (WHO) recommends 4-min overall scrubbing (4MS) for surgical hand hygiene. However, we hypothesize that the more methodical 10-stroke counting technique (10SS) via locational partitioning of the arm is superior to WHO's superficial guideline dictating only the duration. PURPOSE: The mechanical efficiency of 4MS and 10SS techniques are compared. METHODS: 24 healthcare professionals were recruited for the study. A novel methodology was devised to quantify the average brightness change of skin-applied UV ink before and after scrubbing via pixel intensity analysis. A black-box setup is constructed with an integrated high-resolution camera to photograph the UV-stained dorsal arm. Each stain was then digitally isolated for brightness comparison. RESULTS: It was observed that the 10SS technique was overall more successful in removing the UV ink in comparison to the 4MS method (p = 0.014). In addition, a bias was observed in removing more percentage of the proximal stains when compared to middle and distal stains with the 4MS technique (p = 0.0027), while location-based brightness change averages were statistically equal with the 10SS technique (p = 0.423). CONCLUSIONS AND CLINICAL RELEVANCE: 10SS provided not only a more mechanically efficient scrubbing but also a more homogenous cleaning than 4MS. We recommend the use of the 10SS technique to achieve more effective pre-surgical hand hygiene.

Intraosseous calcific tendinitis of the rotator cuff yields similar outcomes to those of intratendinous lesions despite worse preoperative scores.

PURPOSE: To evaluate the surgical outcomes of arthroscopic removal of intraosseous deposits in patients with intraosseous calcific tendinitis of the rotator cuff. METHODS: This study involved a retrospective review of 96 patients operated on from 2004 to 2019. Patients were divided into two groups according to the location of calcific deposits. Group I had pure tendinous involvement (n = 71), and Group II had tendinous and intraosseous involvement (n = 25). The mean follow-up time was 6.4 ± 3.9 years. There were 71 patients (46 women, 25 men) in Group I, and the mean age was 49.3 ± 8.2 years (range 30-65 years). In group II, there were 25 patients (18 women, 7 men); the mean age was 47.3 ± 11.2 years (range 28-70 years). RESULTS: The mean preoperative VAS pain score was 8.8 ± 1.4 in Group I compared to 9.5 ± 0.5 in group II (p = 0.017). The median preoperative Constant and Oxford scores were 42 (20-65) and 22 (8-34) in Group I and 25.5 (22-46) and 10 (8-16) in group II, respectively (p < 0.001). There was no difference in postoperative pain scores (Group I: 0.7 ± 1.6 and group II: 0.5 ± 0.6, p = 0.926), Constant scores [Group I: 100 (80-100) and group II: 100 (90-100), (n.s).] and Oxford scores [Group I: 48 (28-48) and group II: 46.5 (4-48), (n.s.)] between the two groups. The number of preoperative injections was higher in Group II (p = 0.05). There was no correlation between the size of the soft tissue calcific deposit and the preoperative pain, Constant, and Oxford scores (n.s.). CONCLUSION: Arthroscopic debridement of calcific tendinitis with intraosseous involvement is a safe and effective treatment method similar to that of pure tendinous involvement. LEVEL OF EVIDENCE: III.

A novel lower bound for tip-apex distance.

PURPOSE: The cut-out of the cephalomedullary nail is among the most common post-surgery complications for intertrochanteric fractures. As a risk predictor, a tip-apex distance (TAD) below 25 mm, observed from orthogonal fluoroscopic views, is recommended in the literature. This study aims to demonstrate that TAD < 25 mm is a mathematically insufficient risk definition and to complement the TAD upper bound with an appropriate lower bound, with the introduction of a novel distance parameter, TADX, based on the orthogonal projection of the nail tip on the central femoral midline. METHOD: Through a mathematical simulation software, all the possible points that lie inside the AP and lateral views of the proximal femoral hemisphere are utilized to create a 3D grid that is sorted into geometrically safe and risk-bearing regions. Extending this methodology, TAD < 25 mm, 10 mm < TAD < 25 mm, and the ideal tip position volumes are simulated. Finally, intersection volumes are created by a combination of different candidate lower TADX bounds and TAD < 25 mm upper bound to determine satisfactory TADX limits. RESULTS: Simulation of TAD-bound zones exposed that TAD is only a mathematically suitable parameter for defining the upper boundary but not the lower boundary for the optimal region. However, using a TADX lower limit creates a 3D volume that is much closer to the optimal tip region volumetrically and can still be as quickly calculated from 2D AP and lateral views. CONCLUSIONS: According to the mathematical simulations, the use of a TADX lower bound of 9 mm for small, 7.5 mm for medium, and 7 mm for large femoral heads in conjunction with a TAD upper bound of 25 mm is suggested.

The safety and accuracy of the fluoroscopic imaging during proximal femoral fixation: A computerized 3D reappraisal of the joint penetration risk.

BACKGROUND: To assess the success of proximal cephalomedullary nailing operations for treating trochanteric fractures, surgeons utilize 2D fluoroscopy to observe the relative positions of the femoral head and the implant. One distance-based risk parameter, observed from the AP and Lateral projections, is the Tip-Surface Distance(TSD) that dictates how close to the outer cortex should the implant tip be residing to avoid post-surgical complications such as cut-out or joint penetration. In this study, the safety and the accuracy of the orthogonal fluoroscopic imaging were evaluated. METHODS: A femoral head model was created and the risk zone was defined as a hemispherical shell of 5 mm thickness beneath the subchondral cortex, which should not be violated during screw insertion. The remaining hemisphere beneath the risk zone was designated as the safe zone. To assess the effect of head size, each simulation was conducted for 34, 47, and 60 mm diameter(Dfemur) femoral heads. The rate of safe zone violation was calculated for all possible screw endpoints with a TSD of at least 5 mm on fluoroscopic orthogonal views (TSDAP and TSDLat). RESULTS: The minimum risk of joint penetration was achieved when the TSDAP/TSDLat ratio was 1. For Dfemur of 34 mm there was a risk of 91.7% of the safe zone violation when each TSDAP and TSDLat were 5 mm and 0% for 9 mm. For Dfemur of 47 mm, the risk was 92.2% for 5 mm and 0% for 11 mm. For Dfemur of 60 mm, the risk was 92.3% for 5 mm and 0% for 13 mm. Safety maps were constructed for all possible TSD combinations for 34, 47, and 60 mm femoral heads. CONCLUSIONS: Depending solely on the orthogonal fluoroscopic images is not a safe and accurate technique for assessing joint penetration risk during proximal femoral fixation due to the spherical geometry of the femoral head. The screw tip can lie completely outside of the femoral head even when it appears inside, in both orthogonal fluoroscopic views. Evidently, when using TSD, more stringent distance limits should be chosen, contrary to the recommended 5 mm limit. Our safety maps for TSD combinations may be used to check the security of the implantation.

Latarjet procedure using subscapularis split approach offers better rotational endurance than partial tenotomy for anterior shoulder instability.

PURPOSE: Latarjet, which is a coracoid bone block procedure, is an effective treatment for anterior shoulder instability with glenoid bone loss. During this reconstructive procedure the subscapularis may be tenotomized or be split to expose the glenoid neck. The aim of this study was to assess the effect of subscapularis management on functional outcomes and internal and external rotation durability and strength. Hypothesis is that the subscapularis split approach will result in better functional results and superior internal rotation strength and endurance. METHODS: The study included 48 patients [median age 30 (range 16-69); 42 males, 6 females], who underwent a modified Latarjet procedure for anterior shoulder instability. There were 20 patients in the subscapularis tenotomy group and 28 patients in the subscapularis split group. The groups were compared isokinetically using a computerized dynamometer for internal and external rotation durability and strength. At the latest follow-up, the patients were evaluated with the American Shoulder and Elbow Surgeons (ASES) and ROWE scores for functional outcomes. RESULTS: At a median follow-up period of 25 (range 12-73) months after the Latarjet procedure, the internal rotation durability was significantly higher in the split group (p = 0.045). However, a statistically significant difference could not be found for internal and external rotational strengths (n.s.). There was also no significant difference between the final ASES and ROWE scores (n.s.). CONCLUSION: Although both approaches offer promising results, the subscapularis split approach appears to provide better internal rotation durability compared to subscapularis tenotomy. Therefore, the subscapularis split approach may be more preferable for the management of the subscapularis muscle during Latarjet procedure. LEVEL OF EVIDENCE: Retrospective cohort study, Level III.

A Knotless Labro-Bicipital Repair Technique for SLAP Lesions.

Fixation methods for SLAP lesions are still controversial, and the strength of the fixation, suture and knot irritation, and placement and number of anchors are still being discussed. This uncertainty is directly related to the function and anatomy of the superior labrum and attached biceps. Knotless fixation methods close to the biceps anchorage at the 12-o'clock position are favored in recent literature. We describe a practical SLAP repair technique, with a mattress configuration through the biceps anchorage, using a single knotless anchor. Fixing the biceps attachment instead of the labrum alone, in proximity to the biceps, without sutures or knots left in contact with the other intra-articular structures is the superiority of the described technique.

Tibial torus and toddler's fractures misdiagnosed as transient synovitis: a case series.

INTRODUCTION: The high incidence of transient synovitis in early childhood makes it the first suspected pathology in a limping child. Trauma, which has long been regarded as a causative factor for transient synovitis, may be underestimated in a non-cooperative toddler.After excluding most serious conditions, such as septic arthritis, a speculative diagnosis of transient synovitis can be made, and this can easily mask a subtle musculoskeletal injury. CASE PRESENTATIONS: We report the cases of three Caucasian patients (two boys, aged 20-months- and three-years-old, and one girl, aged two-years-old), with tibial torus and toddler's fractures which were late-diagnosed due to an initial misdiagnosis of transient synovitis of the hip. CONCLUSION: In a non-cooperative child musculoskeletal trauma can be mistaken as a simple causative factor for transient synovitis of the hip and this can easily prevent further investigation for a possible subtle musculoskeletal injury of the lower extremities.Our experience with the presented cases suggests the need to be more vigilant in the differential diagnosis of transient synovitis in young children.

Clinical variability of familial tumoral calcinosis caused by novel GALNT3 mutations.

The GALNT3 gene encodes GalNAc-T3, which prevents degradation of the phosphaturic hormone, fibroblast growth factor 23 (FGF23). Biallelic mutations in either GALNT3 or FGF23 result in hyperphosphatemic familial tumoral calcinosis or its variant, hyperostosis-hyperphosphatemia syndrome. Tumoral calcinosis is characterized by the presence of ectopic calcifications around major joints, whereas hyperostosis-hyperphosphatemia syndrome is characterized by recurrent long bone lesions with hyperostosis. Here we investigated four patients with hyperphosphatemia and clinical manifestations including tumoral calcinosis and/or hyperostosis-hyperphosphatemia syndrome to determine underlying genetic cause and delineate phenotypic heterogeneity of these disorders. Mutational analysis of FGF23 and GALNT3 in these patients revealed novel homozygous mutations in GALNT3. Although the presence of massive calcifications, cortical hyperostosis, or dental anomalies was not shared by all patients, all had persistent hyperphosphatemia. Three of the patients also had inappropriately normal 1,25-dihyroxyvitamin D [1,25(OH)(2)D] and confirmed low circulating intact FGF23 concentrations. The four novel GALNT3 mutations invariably resulted in hyperphosphatemia as a result of low intact FGF23, but other clinical manifestations were variable. Therefore, tumoral calcinosis and hyperostosis-hyperphosphatemia syndrome represent a continuous spectrum of the same disease caused by increased phosphate levels, rather than two distinct disorders.

Rice body mass formation mimicking a neoplastic disease around the trochanteric bursae of the hip.

Multiple rice body formation is an uncommon inflammatory process. Sometimes it leads to a big mass in unusual locations. Although sometimes associated with bursitis and systemic diseases, such as rheumatoid arthritis, the pathophysiology of this rare entity is still obscure. We present a 29-year-old woman with multiple rice body mass formation in the trochanteric bursa of the left hip. She was operated, and had no recurrence at 18 months after the surgery.

[The calcaneal angles in the Turkish population]. / Türk toplumunda kalkaneus açilari.

OBJECTIVES: The purpose of this study was to determine the calcaneal angles on radiograms of individuals without a calcaneal fracture. METHODS: We retrospectively analyzed a total of 308 digital records of lateral ankle or foot radiographs taken from 268 patients (106 males, 162 females; mean age 42 years; range 18-79 years) without a calcaneal fracture. On these radiographs, the reference lines were drawn with the use of an angle measurement software with a sensitivity of 1/100 mm and the Böhler (BA) and Gissane (GA) angles were measured. The distribution characteristics of the angles with respect to age, gender, and side of the body were analyzed and compared with those of previous studies. RESULTS: The mean BA was 33.8 + or - 4.8 degrees (range 20 degrees to 46 degrees) and the mean GA was 115.0 + or - 6.5 degrees (range 100 degrees to 133 degrees). There were no significant differences for both angles with respect to measurements obtained from the right and left sides (for BA, p=0.198; for GA, p=0.601) and from both sexes (for BA, p=0.177; for GA, p=0.412). The highest (35.2 degrees) and lowest (32.3 degrees) means of BA were seen in the age brackets of 41-50 and 61-83 years, respectively. The corresponding age brackets for GA were 21-30 and 51-60 years with 115.7 degrees and 114.4 degrees , respectively. There were no significant differences between the age groups for both angles (for BA, p=0.086; for GA, p=0.955). Of note, the mean BA was significantly higher than those reported in previous studies. There was no correlation between BA and GA (r=0.018; p=0.76), nor between the calcaneal angles and age (for BA, r=-0.092; p=0.11 and for GA, r=-0.070; p=0.22). CONCLUSION: The calcaneal angles show considerable variations in diverse ethnic groups and populations in terms of normal range, age, gender, and side. The ranges herein reported (20-46 degrees for BA, 100-133 degrees for GA) can be used as reference values for the Turkish population.

[An unusual cause of shoulder pain: stress fracture of the clavicle]. / Nadir görülen bir omuz agrisi nedeni: Klavikula stres kirigi.

We report a case of stress fracture of the clavicle in which diagnosis was delayed due to the unusual localization of pain and absence of predisposing risk factors. A 34-year-old woman presented with severe right-sided pain in the shoulder, arm, neck, and hemithorax, and numbness in her right upper extremity. Systemic radiographs, cervical and brachial plexus magnetic resonance imaging (MRI) and thorax computed tomography (CT) did not show any pathology. In a retrospective review of the shoulder MRI sections, an edematous appearance was noted in the right clavicle and adjacent soft tissues, suggesting a stress fracture of the clavicle. The patient was followed-up with activity limitation and analgesic treatment and her complaints subsided gradually. Control radiographs obtained 10 months later showed fracture healing with atypical callus formation. Stress fractures of the clavicle must be kept in mind in the differential diagnosis of shoulder pain presenting as an atypical severe arm pain radiating to the upper extremity and hemithorax. In suspected cases, it may be helpful to obtain CT and MRI sections parallel to the long axis of the clavicle.

Unrecognized anterior compartment syndrome following ankle fracture surgery: a case report.

A 35-year-old male sustained a lateral malleolar fracture while playing football. The fracture was treated by open reduction and internal fixation with a tourniquet. The next day, the patient returned with pain and swelling of the ankle and was admitted again to the hospital with a suspected diagnosis of cellulitis. Ten hours later, the patient developed the symptoms of anterior compartment syndrome. Emergency open fasciotomy of the anterior compartment was performed. The retrospective analysis of the patient's history was suggestive of a predisposition to an exercise-induced compartment syndrome. We think that exertional increase of the compartmental pressure before the injury and the tourniquet used during surgery contributed together to the development of compartment syndrome. Physicians should be vigilant in identifying the features of compartment syndrome when managing patients injured during a sporting activity.

A two-portal posterior endoscopic approach in the treatment of a complex talus fracture: a case report.

The two-portal hindfoot endoscopy is a relatively new technique that is becoming increasingly popular. It gives excellent access to the posterior ankle compartment, the subtalar joint, and extra-articular structures. We report a 24-year-old man with a complex talus fracture involving the posterior part of the talar body and posterolateral process. He was treated endoscopically, with a two-portal posterior approach to the hindfoot. This approach allowed a better visualization and treatment of accompanying pathologies. Combined excision of the posterolateral process and fixation of the fracture was performed with the two-portal hindfoot endoscopy, which has not been previously described to our knowledge. The two-portal posterior endoscopic approach can be an attractive treatment alternative for the posterior part fractures of the talus, which can in turn, be a new indication for this technique.

Arthroscopic removal of intraosseous and intratendinous deposits in calcifying tendinitis of the rotator cuff.

PURPOSE: The purpose of this study was to evaluate the surgical outcome of arthroscopic removal of intraosseous deposits in calcifying tendinitis of the rotator cuff. METHODS: We studied the results of arthroscopic treatment in 30 shoulders in 28 patients with calcifying tendinitis (mean age, 48.3 years; age range, 26 to 83 years), with a mean follow-up of 38 months. According to the localization of calcification, the patients were divided into 2 groups: those with pure tendinous/soft-tissue involvement (n = 25) (group I) and those with tendinous/soft-tissue and osseous involvement (n = 5) (group II). After routine tendon debridement, debridement and curettage of the bone lesion were also performed in patients with bone involvement. Clinical outcome was evaluated by use of the pain score on a visual analog scale and the Constant score, and a special inquiry was used for self-assessment. RESULTS: The pain scores and functional Constant scores improved significantly after the operation in both groups (P = .043 for pain score and P = .0001 for Constant score in group I and P = .042 for pain score and P = .0001 for Constant score in group II). The median Constant score increased from 42 (range, 22 to 65) preoperatively to 100 (range, 80 to 100) postoperatively in group I and from 40 (range, 25 to 55) to 100 (range, 85 to 100) in group II. The mean pain score was 6.5 +/- 1.4 (range, 4 to 9) before treatment and 0.2 +/- 0.5 (range, 0 to 2) at follow-up in group I, and it was 6.2 +/- 1.48 (range, 4 to 8) and 0.4 +/- 0.55 (range, 0 to 1), respectively, in group II. There was no significant difference between the 2 groups in terms of the final Constant (P = .85) and pain scores (P = .26). CONCLUSIONS: Arthroscopic removal of intraosseous and intratendinous deposits to treat calcifying tendinitis with osseous involvement seems to be as safe and effective a treatment method as the arthroscopic removal of intratendinous deposits in cases of tendinous involvement only. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

[An unusual complication after syndesmotic injury: retrotibial heterotopic ossification]. / Sindezmoz yaralanmasi sonrasi siradisi bir komplikasyon: Retrotibial heterotopik ossifikasyon.

A 27-year-old male patient sustained an isolated syndesmotic injury in the right ankle following a fall. His complaints subsided gradually within the first six weeks of conservative treatment. At the end of the third month, he returned to follow-up with posterior ankle pain. Radiological examinations revealed heterotopic ossification adjacent to the posterior inferior tibiofibular ligament and posterior capsule. His complaints disappeared only after local excision of the ossification. Heterotopic ossification may be a cause of persistent pain after ankle ligament injuries.

[Functional results of the parallel-plate technique for complex distal humerus fractures]. / Paralel plak teknigi ile tedavi edilen kompleks humerus distal uç kiriklarinda fonksiyonel sonuçlar.

OBJECTIVES: We evaluated functional results of patients treated with open reduction and internal fixation with the parallel-plate technique for complex distal humerus fractures. METHODS: Twenty-one patients (14 males, 7 females; mean age 47 years; range 16 to 85) underwent open reduction with olecranon osteotomy and internal fixation with the parallel-plate technique for distal humerus fractures accompanied by highly intra-articular or metaphyseal comminution (n=10), intra-articular comminution and osteoporosis (n=7), and intra-articular and metaphyseal comminution with bone loss (n=4). According to the AO classification, there were 12 C3, six C2, and three C1 type fractures. Eight patients had open fractures. The mean time to surgery was six days (range 1 to 17 days). Functional results were evaluated using the Mayo elbow performance score, Jupiter elbow score, and DASH (Disabilities of the Arm, Shoulder and Hand) score. The mean follow-up was 28 months (range 12 to 48 months). RESULTS: The mean total range of motion was 90.2+/-31.1 degrees, flexion was 118.1+/-17.4 degrees, and extension was 27.8+/-17.4 degrees. The mean Mayo elbow performance score and DASH score were 86.1+/-12.6 and 7.6+/-9.5, respectively. According to the Jupiter elbow scores, the results were excellent in seven patients, good in 11 patients, moderate in two patients, and poor in one patient. Radiographically, solid union was achieved in all the patients. Heterotopic ossification of varying degrees was seen in seven patients, two of whom underwent resection of heterotopic ossification due to severe limitation of movement. Debridement was performed in one patient due to the development of deep infection. Chondrolysis of the elbow occurred in one patient. Patients with open fractures had significantly lower range of motion than those with closed fractures (p<0.05), but the Mayo elbow performance score and DASH score did not differ significantly in this respect (p>0.05). CONCLUSION: Functional results are satisfactory in distal humerus fractures treated with stable osteosynthesis and parallel-plate technique that allow early active motion.

[Anconeus arthroplasty: a salvage procedure in recurrent heterotopic ossification]. / Ankoneus artroplastisi: Tekrarlayan heterotopik ossifikasyonda kurtarici bir girisim.

Anconeus interpositional arthroplasty has been used in the treatment of radiocapitellar and radioulnar joint problems occurring after trauma. We performed anconeus interposition arthroplasty in a 31-year-old male patient who developed heterotopic ossification (HTO) in the elbow following surgical treatment of an isolated radial neck fracture. Treatment with implant removal and excision of the radial head resulted in recurrent HTO and a stiff elbow. The patient underwent excision of the heterotrophic new bone and mobilization of the proximal radius. The anconeus muscle was mobilized and interposed between the proximal radius and ulna. Sixteen months after the operation, forearm rotation, elbow flexion and extension increased by 80 degrees , 45 degrees , and 60 degrees , respectively. Control X-rays showed maintenance of the radiohumeral gap without any signs of HTO.

Radiographic and pathological stages of the changes at the bone-cement interface: an in-vivo experimental study.

INTRODUCTION: Chemical and physical effects of cementation cause radiographic and histological changes at bone-cement interface. These changes can be of interest in the assessment of the residual lesions and subsequent recurrences after local resection and cementation of local aggressive tumours. AIM: The aim of the study was to evaluate the evolution and determine the stages of the changes that occur at the bone-cement interface after cementation of cavitary lesions. MATERIAL AND METHODS: We operated on 16 hind legs of 8 sheep (Ovies Aries) under general anaesthesia (Xylasin HCl, Ketamin HCl and Forane). A bone cavity of 12 cm(3) was produced by curettage of the distal femoral condyle and was filled with cement. Control radiographs were taken at 2 days; 3, 6 and 12 weeks, and again at 6 months. One sheep each time was killed after second day and sixth month and two sheep each time after the third, sixth and 12th week and the specimens underwent pathological examination. RESULTS: After the first 3 weeks, a reactive fibrous membrane was detected on pathological examinations. This membrane consisted of granulation tissue, necrotic bone and bone marrow, which were replaced gradually by fibrous tissue. The radiographic revelation of this fibrous membrane was a radiolucent zone of 0.5-1.5 mm at 3 weeks. A Sclerotic rim appeared around this radiolucent zone at 6 weeks. With new bone formation the fibrous membrane disappeared at 3 months. This was seen on radiographs as the replacement of the radiolucent zone by a sclerotic ring of 0.5-2 mm. This sclerotic ring disappeared at 6 months, when a diffuse sclerosis and cortical bone thickening was detected on radiographs. DISCUSSION: According to our findings we suggest to consider the pathological processes at the bone-cement interface in 3 phases: (1) Reactive phase (first 3 weeks); (2) Resorption phase (3-6 weeks), and (3) Formation phase (6 weeks to 6 months). We have distinguished five different radiographic stages: Stage 1-Early stage with no apparent zone (first 3 weeks); Stage 2-Radiolucent zone (3-6 weeks); Stage 3-Radiolucent zone with a sclerotic rime (6 weeks to 3 months); Stage 4-sclerotic ring (after 3 months) and Stage 5-Diffuse cortical thickening (after 6 months). Determining the phases of tissue reaction after cementation and its radiographic revelation will ease the diagnosis of residual lesions and subsequent recurrences after local resection and cementation of local aggressive tumors.

[Treatment of Neer type 4 impacted valgus fractures of the proximal humerus with open reduction, elevation, and grafting]. / Valgus impakte Neer tip 4 humerus üst uç kiriklarinda açik redüksiyon, yükseltme ve greftleme.

OBJECTIVES: We evaluated the clinical and radiographic results of minimal invasive surgery, with elevation of the head and tricortical iliac grafting for Neer type 4 impacted valgus fractures. METHODS: Ten patients (6 females, 4 males; mean age 54 years; range 35 to 67 years) with Neer type 4 impacted valgus fractures of the proximal humerus underwent biological reconstruction including open reduction, elevation of the head fragment, grafting, and suture fixation of tuberosities. All the patients were assessed by computed tomography preoperatively. Tricortical iliac crest autograft was used in three patients and lyophilized iliac allograft was used in seven patients. The mean time to surgery was three days (range 1 to 10 days). Radiographic and clinical results were evaluated after a mean follow-up of 38.8 months (range 24 to 49 months). Constant and DASH (disabilities of the arm, shoulder and hand) scores were used for functional evaluation. RESULTS: All the fractures united within six to eight weeks. On final examinations, the mean forward flexion of the shoulder was 154 degrees (range 120 degrees to 175 degrees ) and external rotation was 44 degrees (35 degrees to 55 degrees ). The mean Constant and DASH scores were 81.5 (range 72 to 90) and 23 (range 17 to 38), respectively. The mean inclination angle of the humerus head decreased from 178 degrees (170 degrees -200 degrees ) to 134 degrees (130 degrees -145 degrees ) postoperatively. None of the patients had signs of osteonecrosis in the humeral head. All the patients were pleased with the outcome. CONCLUSION: The biologic reconstruction technique used with graft support may be an effective alternative treatment in selected patients with type 4 valgus impacted fractures of the proximal humerus.