Comparative Study of Minimally Invasive Plate Osteosynthesis (MIPO) and Intramedullary Nailing (IMN) for Treating Extraarticular Distal Tibial Fractures: Clinical and Radiological Outcomes

BACKGROUND Treatment of extra-articular distal tibial fractures is problematic owing to limited soft tissue cover, poor vascularity of the location, and adjacency to the ankle, and thus continues to be controversial. This study aimed to compare clinical and radiological outcomes in 69 patients with extra-articular distal tibia fractures treated with minimally invasive plate osteosynthesis (MIPO) and an interlocking intramedullary nail (IMN). MATERIAL AND METHODS Sixty-nine patients, with mean of age 39.8±18.3 years, were retrospectively evaluated. Thirty-five patients were treated with IMN, and 34 patients were treated with MIPO. Clinical and radiological outcomes were evaluated. RESULTS The average follow-up was 13.3±6 months and union time was 16.2±5.4 weeks. Nonunion was observed in only 4.3% of patients treated with MIPO (P=0.114). Non-acceptable malalignment of extremity was observed in 4.3% of patients with IMN and 7.2% of patients with MIPO. There were no significant differences in union time, nonunion, surgical timing, operating time, malalignment, and complications between groups (P>0.05). The mean American Orthopaedic Foot and Ankle Society (AOFAS) surgery score was 95.8±5 in IMN and 91.9±14.3 in MIPO. AOFAS, Tenny-Wiss radiological, and Ovadia-Beals clinical scores were better in IMN than MIPO (P=0.019, P=0.03, P=0.02, respectively). Mean time of full weight-bearing and of return to daily life with IMN was significantly shorter than with MIPO (P.

Effectiveness of Iloprost in the Treatment of Bone Marrow Edema

Background and objective

Bone marrow edema (BME) is a rare condition caused by insufficient osseous blood supply and may result in severe pain that has adverse effects on patients’ life. To date, various conservative treatments have been recommended for the treatment of BME, including analgesics, immobilization of the affected extremity, and iloprost infusion. The aim of this retrospective study was to investigate the effectiveness of parenteral iloprost therapy in the treatment of BME detected in different skeletal locations.

Materials and methods

This retrospective study included 23 patients (17 men and six women) with BME who were classified as stage I-III according to the Association Research Circulation Osseous (ARCO) classification. BME was localized to the proximal femur in 13 (56.5%), the distal femur in four (17.4%), tarsal bone in four (17.4%), and tibial plateau in two (8.7%) patients. The mean age of the patients was 46.7 years and all the patients were evaluated with the Visual Analog scale (VAS), Functional Mobility Scale (FMS), and MRI.

Results

A significant improvement was observed in the post-treatment VAS and FMS scores of all patients compared to their pre-treatment scores. Moreover, the edema regressed completely in 60.9% of the patients at three months of MRI control. No serious side effects were observed during the treatment in any of the patients. However, transient side effects including headache, arrhythmia, and flushing were observed in five patients.

Conclusion

The present study indicated that iloprost therapy is an effective and safe option in the treatment of BME patients, particularly in the reduction of severe pain that has adverse effects on patients’ social life, regardless of ARCO staging. Moreover, this therapy could be particularly useful in reducing pain, improving functional recovery, and achieving complete regression of the edema on MRI in ARCO stage I-II patients.

Comparison of Three Different Approaches in Pediatric Gartland Type 3 Supracondylar Humerus Fractures Treated With Cross-Pinning

Introduction

Although closed reduction and percutaneous pinning are the accepted treatment approaches in pediatric humerus supracondylar fractures, the treatment approach in fractures without closed reduction remains unclear. This study compared the results of three different cross-pinning treatment methods.

Materials and methods

A total of 62 patients (1-13 years old) who were operated for Gartland type 3 humerus supracondylar fractures between 2007 and 2016 were evaluated retrospectively. Of the patients evaluated, 24 patients had closed reduction, 25 patients had direct reduction from the medial, and 13 patients had direct reduction from the lateral and cross-pinning. The functional and cosmetic results of the patients were evaluated according to Flynn's criteria. In addition, the Baumann angle, lateral capitellohumeral angle (LCHA), and postoperative complications were compared among groups.

Results

Both functional and cosmetic results and the Bauman and LCHA angles were similar in all three groups. In patients with open reduction, the control duration was significantly longer than that in patients with closed reduction, and this difference was due to a recent increase in the surgeons' preference for closed surgery. Two patients underwent pin site infection and two patients developed nerve palsy. Only the first patient who developed ulnar nerve palsy recovered during follow-up. Secondary surgery was applied to the other patient who developed brachial artery occlusion with ulnar and median nerve paralysis, and they recovered during follow-up. Three patients who underwent open surgery from the medial, along with the two patients who had undergone open surgery, developed pinhole infection. These patients were subsequently recovered with antibiotherapy without further complications. A patient who underwent open lateral surgery developed compartment syndrome and fasciotomy was performed.

Conclusion

Closed reduction and percutaneous pinning are generally accepted approaches in the treatment of pediatric humerus supracondylar type 3 fractures. However, in cases where closed reduction cannot be achieved, pinning with the medial approach and taking the ulnar nerve and medial colon is a reliable method to avoid both ulnar nerve injury and cubitus varus.

Comparison of various tendon repair techniques in extansor zone 3 injuries: an experimental biomechanical cadaver study

PURPOSE

To compare five different repair techniques for extensor tendon zone III modified Kessler (MK), double-modified Kessler (DMK), modified Kessler epitendinous (MKE), double-modified Kessler epitendinous (DMKE), and running-interlocking horizontal mattress (RIHM) in terms of shortening, stiffness, gap formation, and ultimate load to failure.

METHODS

A total of 35 human cadaver fingers were randomly assigned to five suture techniques with 7 fingers each and were tested under dynamic and static loading conditions.

RESULTS

DMK was found to be superior over MK in terms of ultimate load to failure (36 N vs. 24 N, respectively), shortening (1.75 vs. 2.20 mm, respectively) and gap formation. However, these two methods had similar characteristics in terms of stiffness. The addition of epitendinous sutures to the repair methods resulted in approximately 40% increase in ultimate load to failure, whereas epitendinous sutures had no effect on shortening. DMKE was found to be superior over MKE in terms of shortening (1.77 vs. 2.22 mm, respectively). However, these two methods had similar characteristics in terms of mean ultimate load to failure and stiffness. RIHM was found to be superior over the other four methods in terms of ultimate load to failure (89 N), stiffness, and shortening (0.75 mm).

CONCLUSION

RIHM was found to be stronger and more durable for extensor tendon zone III than the other techniques in terms of ultimate load to failure and stiffness.

The Effect of Tourniquet Usage and Anesthesia Method on Prognosis in the Treatment of Dorsal Wrist Ganglion Cysts by Open Surgery

Introduction

Ganglion cysts are the most common soft tissue masses seen on the wrist, which often cause pain or cosmetic complaints. The treatment of these masses includes intra-cystic injections or surgery. Recurrence rates are very high in surgical or non-surgical treatment. Inadequate excision for recurrence after surgery is blamed; however, the reasons for the recurrence still remain mysterious.

Objectives

In this study, the effect of anesthesia selection and tourniquet use on the dorsal wrist ganglion cysts in open surgery was investigated.

Materials and methods

Patients with dorsal wrist ganglion cysts, who were operated with open surgery between 2015 and 2018 and who had at least six months after the surgery, were examined. The patients were divided into two groups: patients who underwent surgery without tourniquet with local anesthesia and patients operated with tourniquet with general or regional anesthesia. Age, sex, cause of operation, visual analog scale (VAS) scores before and after surgery, limitation of movement, postoperative complications, and recurrence were compared.

Results

There was no significant difference between the groups in terms of causes of surgery, recurrence rates, preoperative and postoperative limitations of movement, and complications. In terms of age, the group operated with local anesthesia and without tourniquet was significantly larger. There was also no significant difference between the groups in terms of preoperative pain. Postoperative pain was significantly less in the group operated by tourniquet with general-regional anesthesia.

Conclusion

There is no significant difference in the recurrence and complications between patients operated under local anesthesia without tourniquets and patients operated with tourniquets under general or regional anesthesia during the open excision of the dorsal wrist ganglion cysts. However, it should be kept in mind that postoperative pain does not diminish in later ages, especially in cases of ganglion cysts, and other pathologies may also potentially cause pain in the wrist.

Results of 4-strand modified Kessler core suture and epitendinous interlocking suture followed by modified Kleinert protocol for flexor tendon repairs in Zone 2

Objective

There has been no consensus in literature for the ideal flexor tendon repair technique. The results of zone 2 flexor tendon lacerations repaired primarily by 4 strand Modified Kessler core suture and epitendinous interlocking suture technique followed by Modified Kleinert protocol were investigated.

Methods

128 fingers of 89 patients who had flexor tendon laceration in zone 2 built the working group. Functional outcomes were evaluated using the Strickland formula. A statistical analysis was made between Strickland scores and some parameters such as age, gender, follow-up time, co-existing injury existence, repair time, single or multiple finger injury, tendon rupture and the effect of FDS injury and repair.

Results

Excellent, good, fair, poor results were obtained from 71 (55.5%), 46 (35.9%), 8 (6.3%), 3 (2.3%) fingers, respectively. Time of the repair has a significant effect on the strickland scores. Surgery performed within the first 24 hours following the injury gave better results. 3 fingers (2.3%) had tendon ruptures. Existence of ruptures affected the results significantly. Co-existing injuries were found that they did not have any effect on the results. In the fingers in which both FDP and FDS tendons were lacerated, no significant relationship was found between only FDP repair, both FDP and FDS repair and single FDS slip repair. Additionally no significant relationships between follow-up time, gender, single or multiple finger injury and Strickland scores were observed. 13 fingers (10.1%) had PIP joint contracture above 20°.

Conclusion

The low rupture rate (2.3%) and 91.4% ‘good’ and ‘excellent’ scoring rates in our series support the idea that modified Kessler 4-strand core suture and epitendinous interlocking suture repair combined with modified Kleinert protocol gives satisfactory results. Repair time is one of the most important factors affecting the functional results and surgery should not be delayed if there is an experienced surgeon available.

Level of evidence

Level IV, therapeutic study.

Unicameral (simple) and aneurysmal bone cysts: the effect of insufficient curettage on recurrence

INTRODUCTION

Curettage of the cyst and bone grafting are the most common methods used in the treatment of unicameral bone cysts (UBC) and aneurysmal bone cysts (ABC). Recurrence of these cysts is often associated with insufficient curettage of the cyst during surgery. In this study, we aimed to evaluate the effect of insufficient curettage on recurrence in patients with UBC and ABC.

METHODS

The retrospective study included 18 patients with UBC and 14 patients with ABC that were surgically treated by curettage and bone grafting in our clinic between 2006-2013. Mean age was 19.80 (range, 4-50) years in the patients with UBC and 21.76 (range, 4-56) in the patients with ABC. The diagnosis of the cysts was established both clinically and radiologically. Mean follow-up period was 36 (range, 6-60) months both in the patients with UBC and ABC. The patients with recurrence underwent a second curettage and grafting procedure. Healing and recurrence were evaluated according to modified Neer's scale.

RESULTS

Recurrence occurred in 8 patients. Of these, 5 patients underwent a second curettage and grafting procedure and 3 patients were lost to follow-up. Complete healing occurred in all the patients that underwent a second curettage and grafting procedure.

CONCLUSION

The achievement of complete healing in the patients that underwent a second curettage and grafting procedure indicates that the recurrence of UBC and ABC is associated with insufficient curettage.

Prevalence and mutations of β-thalassemia trait and abnormal hemoglobins in premarital screening in Çanakkale province, Turkey

The prevalence of β-thalassemia (β-thal) carriers in Turkey varies according to region but in general it is 2.0%. Çanakkale is a city in the Aegean region of Turkey but no study about β-thal frequency in Çanakkale has been published to date. In this study, we aimed to investigate the frequency of β-thal mutations in this province. A total of 4452 couples (8904 individuals) applied for premarital thalassemia scans at the Çanakkale State Health Directorate Laboratory between January 2008 and June 2012 and scanning was done with high performance liquid chromatography (HPLC). Of 125 β-thal carriers seen at the Medical Genetics Clinic, Çanakkale Onsekiz Mart University, Çanakkale, Turkey, for genetic counseling, 46 participated in the study. The remaining 79 patients could not be reached. The prevalence for β-thal carriers in Çanakkale was identified as 1.4% (125/8904). One couple were both β-thal carriers. β-Globin gene analysis of 46 carriers found the total frequency of the three most common mutations was 45.6%. These mutations were found to be HBB: c.93-21G>A [IVS-I-110 (G>A)], 26.08% (12/46); HBB: c.17_ 18delCT [codon 5 (‒CT)], 10.85% (5/46); HBB: c.20delA [codon 6 (‒A)] 8.69% (4/46). This is the first report on the frequency and mutation profiles of β-thal for Çanakkale. The incidence of β-thal carriers in Çanakkale is below the average for Turkey. The most frequently observed mutation profile and rate of β-thal in our region is different from the other regions of Turkey.

The Effect of Sodium Hyaluronate plus Sodium Chondroitin Sulfate Solution on Peritendinous Adhesion and Tendon Healing: An Experimental Study

BACKGROUND

Adhesion formation following tendon injury is a serious clinical problem.

AIMS

In this experimental study, the effects of the combination of sodium hyaluronate (HA) and chondroitin sulfate (CS) on peritendinous adhesion and tendon healing were evaluated.

STUDY DESIGN

Animal experimentation.

METHODS

Twenty-one mature Sprague Dawley male rats were randomly divided into three equal groups. The rats' Achilles tendons were cut and repaired with a modified Kessler technique. About 0.25 and 0.50 mL of the HA and CS (HA+CS) combination were injected subcutaneously into the repair site of the rats in groups 1 and 2, respectively, on days 0, 3, 7, and 10. The subjects in group 3 were used as the control group. At 6 weeks, all rats were euthanized. The tenotomy site was examined macroscopically in all animal subjects. Four samples were assigned to the histopathological examination group, and the others were assigned to the biomechanical assessment group.

RESULTS

Inflammation and adhesion in both treatment groups were observed at a lower rate than in the control group. The collagen filaments in both treatment groups were regular and the number was low when compared to the control group. However, there was no statistically significant difference between group 1 and the control group. The quantity, quality, and grade of the adhesions were statistically significantly lower in group 2 when compared with the other groups. The mean maximum stress strength in group 2 was statistically significantly higher than that in group 1 and the control group.

CONCLUSION

Local administration of the HA+CS combination solution is a valid tool for preventing peritendinous adhesion after extrasynovial tendon repair such as Achilles tendon, and is a treatment option in such cases.

A rare case of extensive diffuse nonpigmented villonodular synovitis as a cause of total knee arthroplasty failure

INTRODUCTION

Nonpigmented villonodular synovitis (non-PVNS) is a benign proliferative disease involving the synovium. It is a rare condition that is little recognized. Non-PVNS has been reported as a cause of total knee replacement failure.

PRESENTATION OF CASE

We report a case of extensive diffuse non-PVNS in a patient with tibial component loosening after total knee replacement and review the related literature.

DISCUSSION

It is reported that pigmented villonodular synovitis (PVNS) occurs less frequently than non-PVNS after knee replacement. However, there are many more case reports of PVNS than non-PVNS after knee arthroplasty in the English-language literature.

CONCLUSION

Previously, there were no reported cases of extensive diffuse non-PVNS after total knee arthroplasty (TKA). This case study highlights an unusual case of non-PVNS as a cause of TKA failure. We propose that non-PVNS should be considered as a differential diagnosis in patients after TKA who present with recurrent pain and effusion/hemarthrosis of the knee, and that it is one of the causes of implant loosening after TKA.

Nonunion of capitate due to late diagnosis in a teenager

Patient: Male, 13

Final Diagnosis: Isolated capitate bone fracture

Symptoms: —

Medication: —

Clinical Procedure: —

Specialty: —

Successful Treatment of Hemophilic Hand Pseudotumors by Only Radiotherapy

Hemophilic pseudotumor is a rare complication of hemophilia. We describe a 14-year-old young male with hemophilic pseudotumor in the second and fifth fingers of the left hand. We treated him only with radiotherapy. A total dose of 2000 cGy in 10 fractions was administered in 2 weeks. Factor VIII was not given. After 4 months, complete healing was seen. The patient was followed up at 24 months, and there was no evidence of recurrence and no bone growth disturbance. Based on our experience and a review of the literature, radiotherapy can be an effective alternative modality in treating hemophilic pseudotumor.