Ewing's sarcoma of the fibula presenting with venous thrombosis

Malignancies account for about 20% of incidentally diagnosed venous thromboembolism. Surgery- or chemotherapy-induced risk of thrombosis is also high in patients with cancer. We report on a young male with skeletal Ewing's sarcoma who presented with deep vein thrombosis in the affected limb, which is quite a rare clinical condition. Venous thrombosis of the lower extremities in young patients should prompt the clinician to search for underlying local malignancies.

[Removal of a bent inflatable femoral nail: a case report]

Intramedullary nailing is the gold standard for the treatment of diaphyseal femoral fractures. Bending of the nail secondary to trauma is a rare complication encountered in unhealed and comminuted fractures. A 23-year-old man was admitted with refracture of the right femoral shaft and a 32-degree bending of an inflatable intramedullary nail due to a fall, two months after the initial surgical treatment. The nail was first straightened by exerting an external force, which decreased the angulation to 10 degrees. Then, the fracture site was opened, the lateral wall of the nail was drilled, and one of the four metal bars of the nail was cut. This allowed complete straightening of the nail by the same maneuver and its removal. A new inflatable intramedullary nail was placed and union was achieved after four months. Tools that may be necessary to cut the nail partially or totally should be made available for removal of bent nails.

Skin problems in amputees: a descriptive study

BACKGROUND

Skin problems are common in amputee patients. These problems may restrict the normal use of a prosthetic limb. We aimed to determine the range, incidence, causes and patterns of dermatological problems seen in a population of amputees.

MATERIALS AND METHODS

One hundred and forty two amputees, were enrolled to the study. Age, sex, age at the time of amputation, level of amputation, reason for amputation, and types of prosthesis were noted. Dermatological problems were recorded. Stumps were swabbed for bacteriological and mycological examination, and patch tests were performed in suspected patients.

RESULTS

Of these 142 patients, 139 (97.9%) were males and 3 (2.1%) were females. The reasons for amputation in the majority of the cases were wounds due to mine explosion (n = 114, 80.3%) and gunshot wounds (n = 19, 13.4%). The other reasons were arterial diseases, traffic accidents, congenital absence of the tibia, and vascular complication of diabetes. At least one skin problem was detected in 105 (73.9%) of 142 cases. Positive reactions to allergens have been detected in 28 (43%) of 65 cases with dermatitis. Bacterial infection was detected in 12 patients and fungal infection was detected in 4 patients.

CONCLUSION

Our descriptive study shows that skin problems have a high prevalence, up to 73.9% in amputee patients. This high percentage indicates that dermatological problems are important in amputees. Early recognition and treatment of these problems can prevent the amputee's mental, social, and economic losses.

Prophylactic intramedullary nailing in monostotic fibrous dysplasia

Fibrous dysplasia of bone is an enigma with no known cure. Treatment currently consists of curettage and bone-grafting in an attempt to eradicate the lesion and to prevent progressive deformity. This study presents the results of prophylactic intramedullary nailing in 10 patients with monostotic fibrous dysplasia, pain increasing with movement, and scintigraphically established activity. Ten patients with monostotic fibrous dysplasia in their upper or lower extremities treated between 2001 and 2003 were included in the study. Seven patients were male and 3 were female; their mean age was 26.9 years. The mean duration of follow-up was 33.5 months. Closed intramedullary nail without reaming was used in all cases. Bone grafting was not performed. Patients were allowed full weight bearing on the affected extremities on the second postoperative day. Mean VAS for functional pain was 5.33 +/- 0.65 preoperatively and 2.26 +/- 0.57 at final follow-up (p < 0.05). Radiographs showed no changes in lesion size, and the intramedullary fixation appeared to be stable. Prophylactic intramedullary nailing appeared to be beneficial in monostotic fibrous dysplasia with scintigraphically proven activity and functional pain. It also avoids problems that may occur following pathological fracture.

Modified chevron osteotomy fixed with stofella pin for hallux valgus

BACKGROUND

The purpose of this study was to present the mid-term results of hallux valgus patients who underwent a modified chevron osteotomy.

MATERIALS AND METHODS

Fifty-six patients (73 feet) with mild to moderate hallux valgus underwent a modified chevron osteotomy and Stoffella pin fixation between January 1999 and December 2004. Patients were evaluated clinically by the American Orthopedic Foot and Ankle Society (AOFAS) score. Pre- and postoperative radiographs were evaluated for the hallux valgus and intermetatarsal angles and sesamoid position.

RESULTS

An improvement of 44.8 points in the AOFAS score was found. A change of 17.4 degrees in the hallux valgus angle and by 5.3 degrees in the intermetatarsal angle was achieved (p < 0.05). The change in the sesamoid position was significantly improved. Superficial skin infection in 3 cases, transient hypoesthesia in 2 cases, and bursitis due to screw irritation in 4 cases were the complications.

CONCLUSION

Stable and rigid fixation by modified chevron osteotomy using Stoffella pins allows early mobilization and weightbearing without a cast. We believe early mobilization of the joint provides better functional outcomes with fewer complications compared to other fixation techniques.

Neglected patellar tendon rupture: a case of reconstruction without quadriceps lengthening

Neglected rupture of the patellar tendon is a rare, can be easily missed in a group of patients. We present a 24 year old, male patient who sustained right femoral diaphyseal and tibial plateau fractures and a patellar tendon rupture following a motor vehicle accident. The fractures were treated by open reduction internal fixation but the patellar tendon rupture was missed and the diagnosis was delayed by 7 months. Patella was migrated proximally. It was moved distally to the original location and neglected patellar tendon rupture treated successfully with modified Ecker technique. Neither preoperative traction nor additional intraoperative procedures were performed to relocate the patella to its anatomic position in the extended knee and good functional result was achieved with intensive rehabilitation.

First ray reconstruction with distraction osteogenesis

Disarticulation of the thumb at the metacarpophalangeal joint level is not beneficial either aesthetically or functionally without additional surgery because it requires a bulky and an unacceptable prosthesis to be made for this amputation level. In this study, the authors have presented our experience of 12 metacarpal distractions in thumb amputated patients. Twelve male patients who had thumb amputation due to gunshot wounds were included in the study. Before the operation, aesthetic hand prostheses were made for 5 of the 12 patients. Callus distraction was performed with the use of a mini Ilizarov type external fixator in 7 cases and uniplanar dynamic mini external fixator in 5 cases too. External fixators were removed after the completion of the radiographic consolidation. Five patients whose prosthesis had been made before the operation wore their prosthesis for an average 6.8 months (5 - 14) due to poor appearance and poor construction. Union of the lengthened segment was observed in all cases. Average lengthening was 28.9 mm (range from 25 - 37). Average healing time was 2.1 months (range from 1.8 - 2.5). Average healing index was 0.73 month/cm (range from 0.65 - 0.88). Pin tract infection was seen in 7 cases (58.3%). Volar angulation developed after removing the external fixator in 1 case. Webplasty was performed in all cases. Patients were evaluated by means of Disability of the Arm, Shoulder and Hand (DASH) score and pick-up test. It was concluded that the metacarpus lengthening by callus distraction technique may be a functionally and cosmetically effective reconstruction method for traumatic thumb amputations. It is believed that the possibility for a functionally and aesthetically acceptable fabrication of a thumb prosthesis, by providing a suction suspension with distraction and/or webplasty procedures.

No alteration in bone mineral density in patients with periodontitis

Alveolar bone destruction can be magnified in the presence of generalized skeletal disorders. We questioned whether severe generalized periodontitis patients display signs of bone metabolism disturbances. Our objective was to assess skeletal bone mineral density (BMD) and biochemical bone parameters in premenopausal women with periodontitis. Forty-five patients and 40 control individuals were included in the study. We measured BMD by dual-energy x-ray absorptiometry. The results showed no difference in BMD values between the periodontitis and control groups (p > 0.05). A positive relationship between the clinical attachment level and Body Mass Index (BMI) scores was observed (p = 0.03). Increased serum creatinine levels were noted in the periodontitis group (p = 0.04). Analysis of the data suggests that there is no evidence for an association between skeletal BMD and severe periodontitis in premenopausal women. There may be a link between elevated creatinine levels and periodontitis. The persons with high BMI scores seemed to be at risk for periodontitis.

Ankle arthrodesis using an Ilizarov external fixator in patients wounded by landmines and gunshots

BACKGROUND

We evaluated the results of ankle arthrodesis performed with circular external fixators (CEF) in those patients who had developed tibiotalar arthritis secondary to a landmine or a gunshot injury.

MATERIALS AND METHODS

Nineteen ankles in 19 patients were fused using CEF. All patients had approximately 3 (range, 1 to 5) operations for bone and soft tissue reconstruction preceding the arthrodesis. Ankle arthrodesis was performed an average of 2.3 (range, 1 to 7) years after the initial trauma. The mean age at operation was 22 (range, 20 to 31) years old and all patients were male.

RESULTS

The average time spent in the CEF was 3.5 (range, 2 to 7) months. The mean followup was 59 (range, 31 to 90) months. Successful arthrodesis was achieved in all patients in an acceptable position. Clinically, 6 patients were assessed as excellent, 9 patients as good, 3 patients as fair, and 1 patient had a poor result. Twelve patients reported no pain postoperatively, 4 patients reported reduced to mild and/or occasional pain, 2 patients reported moderate pain, and 1 patient reported persistent pain. Sixteen patients described their outcome as satisfactory, one was somewhat satisfied, and two were dissatisfied. There were pin track infections in 10 patients and ring sequestration in one patient.

CONCLUSION

Patients who have degenerative ankle arthritis due to gunshot wounds and land-mine injuries with poor bone quality and soft tissue conditions at the distal tibia can be successfully managed by using CEF.

Total elbow arthroplasty in patients who have elbow fractures caused by gunshot injuries: 8- to 12-year follow-up study

INTRODUCTION

In this retrospective study, we aimed to present 8-12-year clinical and radiographic evaluation of total elbow arthroplasty in young patients who had open fractures due to gunshot injuries.

MATERIALS AND METHODS

The study included a consecutive series of seven patients who had insertion of total elbow prosthesis (semi-constrained type) for the treatment of comminuted intra-articular elbow fractures resulting from gunshot injuries between 1994 and 1998. All patients were male and the mean age at the time of operation was 23 years.

RESULTS

The average time from the original fracture to the joint replacement was 26 months (range 14-39). The mean follow-up period was 117 +/- 15 months. At the time of the latest follow-up, 5 of 7 elbows had a poor result. Radiological evaluations revealed that three patients had ulnar and two patients had humeral component loosening at the last follow-up examination. No intra-operative complications were observed. In the long-term evaluation, two patients had prosthesis loosening that resulted from deep infection and three patients had aseptic loosening that necessitated re-operation. The prosthesis removal was performed.

CONCLUSION

As a result, the patients in whom we implemented total elbow prosthesis in comminuted elbow fractures due to gunshot wounds seemed to get back into active life in the early period without any problem and it seemed that their pain disappeared and their functional capacity increased. In the long period, however, these values showed a distinct decrease with the same patients.

Successful Treatment of Osteosarcoma Arising in Osteogenesis Imperfecta with High-Dose Chemotherapy and Autologous Peripheral Blood Stem Cell Transplantation Followed-by Limb Sparing Surgery

We present a 20-year-old male patient with localized osteosarcoma arising in osteogenesis imperfecta who underwent high-dose chemotherapy together with autologous peripheral blood stem cell transplantation followed-by a successful extremity sparing surgery.

An uncommon presentation of malignant fibrous histiocytoma of the calcaneus

Malignant fibrous histiocytoma of bone is the osseous counterpart of the tumor in soft tissue. It is a rare primary bone tumor, and there have been conflicting reports on its grades of malignancy. The appendicular skeleton, especially the femur, is the most common site of involvement, whereas the calcaneus is rarely involved. We describe a primary malignant fibrous histiocytoma of the calcaneal bone in a 21-year-old man. The patient underwent neoadjuvant and adjuvant chemotherapy and below-the-knee amputation, and no local recurrence or metastasis was noted after 2 years of follow-up.

Bilateral femoral insuffiency fractures treated with inflatable intramedullary nails: a case report

Stress fractures could be classified as fatigue fractures and insufficiency fractures (IF). Fatigue fractures occur when abnormal mechanical stress is applied to a normal bone, on the other hand insufficiency fractures occur when normal to moderate pressure is applied to a bone that has decreased resistance (Daffner and Pavlov in Am J Radiol 159:242-245, 1992). IF have been observed mainly in patients with postmenopausal osteoporosis, and are becoming more common with the increase of elderly population (Daffner and Pavlov in Am J Radiol 159:242-245, 1992). Other systemic and metabolic conditions that can result in osteopenia and IF include osteomalacia, hyperparathyroidism, hyperthyroidism, rheumatoid arthritis, fluoride treatment, diabetes mellitus, fibrous dysplasia, Paget's disease, irradiation and mechanical factors (Daffner and Pavlov in Am J Radiol 159:242-245, 1992; Soubrier et al. in Joint Bone Spine 70:209-218, 2003; Epps et al. in Am J Orthop 33:457-460, 2004; Austin and Chrissos in Orthopedics 28:795-797, 2005). In this case report, the authors present an osteoporotic woman who developed bilateral insufficiency fracture of the femoral shaft after longstanding steroid, thyroxine replacement and alendronate therapy due to partial empty sella syndrome and osteoporosis, resulting in the treatment of the fracture by inflatable intramedullary nailing.

Type 1 neurofibromatosis and adult extremity sarcoma. A report of two cases

We report two cases of malignant soft-tissue tumours--one myxoid malignant fibrous histiocytoma and one pleomorphic rhabdomyosarcoma--which were diagnosed in two young adult patients with type 1 neurofibromatosis (NF 1). The patients were evaluated with criteria for Neurofibromatosis 1 and NF 1 gene analysis was performed. Four of seven criteria were found in both patients. The tumours were stage II and III respectively. Both patients were treated with radiotherapy or chemotherapy and surgical intervention. Diagnoses of myxoid malignant fibrous histiocytoma and pleomorphic rhabdomyosarcoma in adult NF 1 patients are exceedingly rare. Thus detection of subtypes of rhabdomyosarcoma and malignant fibrous histiocytoma with immunohistochemistry may be helpful for the management of these tumours among other pleomorphic sarcomas that may occur in type 1 Neurofibromatosis.

Spiral and Oblique Fractures of Distal One-Third of Tibia-Fibula: Treatment Results with Circular External Fixator

Introduction: Spiral and oblique fractures of distal 1/3 of tibia-fibula are relatively common fractures of long bones. Due to their types, aetiology, limited coverage and blood supply, these fractures often lead to union and soft tissue problems. Materials and Methods: Twenty-seven patients with spiral and oblique fractures of distal 1/3 of tibia-fibula were treated with circular external fixator (CEF) between January 1997 and August 2000. All the fractures were closed. The type of fractures based on AO classification were A1 (n = 8), A2 (n = 6), B1 (n = 11) and C1 (n = 2). Results: The mean framing time was 14.1 ± 1.8 weeks (range, 12 to 19 weeks), and the mean treatment time was 18.8 ± 2.2 weeks (range, 15 to 24 weeks). The patients were followed up for 36 to 78 months (mean follow-up time: 51.9 ± 10.4 months). The results were evaluated for shortness, angulation, rotation, ankle stiffness, pain and infection. After removal of the frames, 11 patients had ankle pain and stiffness, and 3 patients had loss of range of motion in the ankle even after rehabilitation. None of the patients suffered any complications such as shortness, angulation, rotational deformity and infection, and none had loss of motion in the knee. Conclusions: CEF might be a preferable alternative treatment for distal tibia-fibula fractures due to its easy application, fewer major complications such as shortness and angulation, early mobilisation and shorter treatment time. Key words: Distal tibia, External fixation, Ilizarov, Oblique fractures

Spiral and oblique fractures of distal one-third of tibia-fibula: treatment results with circular external fixator

INTRODUCTION

Spiral and oblique fractures of distal 1/3 of tibia-fibula are relatively common fractures of long bones. Due to their types, aetiology, limited coverage and blood supply, these fractures often lead to union and soft tissue problems.

MATERIALS AND METHODS

Twenty-seven patients with spiral and oblique fractures of distal 1/3 of tibia-fibula were treated with circular external fixator (CEF) between January 1997 and August 2000. All the fractures were closed. The type of fractures based on AO classification were A1 (n = 8), A2 (n = 6), B1 (n = 11) and C1 (n = 2).

RESULTS

The mean framing time was 14.1 +/- 1.8 weeks (range, 12 to 19 weeks), and the mean treatment time was 18.8 +/- 2.2 weeks (range, 15 to 24 weeks). The patients were followed up for 36 to 78 months (mean follow-up time: 51.9 +/- 10.4 months). The results were evaluated for shortness, angulation, rotation, ankle stiffness, pain and infection. After removal of the frames, 11 patients had ankle pain and stiffness, and 3 patients had loss of range of motion in the ankle even after rehabilitation. None of the patients suffered any complications such as shortness, angulation, rotational deformity and infection, and none had loss of motion in the knee.

CONCLUSIONS

CEF might be a preferable alternative treatment for distal tibia-fibula fractures due to its easy application, fewer major complications such as shortness and angulation, early mobilisation and shorter treatment time.

Preliminary results of the use of Ilizarov fixation in clavicular non-union

Although clavicular fractures are common, nonunion of clavicle is a rare complication. Clavicular nonunion that occurs due to insufficient stabilization is usually painful and necessitates operative treatment. Seven cases with oligotrophic clavicular nonunion that developed after a conservative process were treated with Ilizarov between January 2000 and December 2002. In all of them, the middle one-third of the clavicle was affected. Details of the cases regarding sex, age information, reason of fracture, previous treatment methods that were applied, nonunion area, nonunion, and duration of frame application were recorded. Two of the cases were female and five of them were male with age mean of 27.1 (19-32 years). Five of these cases had right clavicular injury and two of them had left clavicular injury. Mean nonunion duration was 18 months (range was 6-36 months). All nonunion were fixed and went through acute compression by means of Ilizarov's external fixators without grafting. The duration between the frame application and union was mean 2.7 months (range was 2.5-3.5 months). Mean follow-up period was 31 months (range was 22-48 months). Cases were evaluated in accordance with the Constant Scoring system. They were able to return to their normal daily activities in 10-15 days. All of them regained full shoulder movement and extension ability. Patients have also been evaluated by using Dash-Score. Union existed for all patients and none of them had any complaints of pain after treatment. Since circular external fixator allows acute compression, early shoulder movements, and requires no such additional procedure as grafting, it is an alternative method which can be used in treating nonunion of clavicle.

Application of Circular External Fixator under Arthroscopic Control in Comminuted Patella Fractures: Technique and Early Results

BACKGROUND

Comminuted fractures of the patella are traditionally treated by internal fixation. The modified tension-band technique is widely accepted for internal fixation. The management of comminuted fractures often requires additional K-wire and/or circlage material and wide surgical exposure. Therefore, symptoms and complications related to the stainless steel wire are not uncommon in these cases. We present a new alternative treatment technique for comminuted patellar fractures.

METHODS

Five comminuted patellar fractures of four patients were treated by circular external fixator (CEF) under arthroscopic control. The mean patient age was 32.5 (range 24-41) years and mean follow-up was 22 (range 20-28) months.

RESULTS

In four cases, union was completed by the sixth week; in the other case, union was completed by the eighth week. The frames were removed after union of the fracture was documented. When the CEF was removed, full knee range of motion was observed full in all patients, and the patients returned to their normal activities of living in a few days. The mean Lysholm score was 94 (range 85-100) after treatment.

CONCLUSIONS

CEF application under arthroscopic control can help avoid some complications of the traditional treatment methods, particularly in comminuted fractures of the patella. The most important advantage of this technique is to allow active knee motion in the early postoperative period so patients can return to activity of daily living soon after the implant removal. In addition, arthroscopic examination of the knee joint provides an assessment of any other intra-articular lesions. This technique allows healing of the fracture with low morbidity.

[The relationship between phantom limb pain and neuroma]

OBJECTIVES

We evaluated the effect of exploratory neurectomy on phantom limb pain (PLP) in patients who had PLP and neuroma findings in the amputated extremity.

METHODS

The study included 14 patients (13 males, 1 female; mean age 30 years; range 21 to 54 years) who developed symptomatic neurinoma and PLP following amputation of an extremity due to trauma (9 mine blasts, 5 traffic accidents). Postamputation period ranged from 2.5 to 17 years (mean 5.5 years). All the patients had PLP of varying intensity and neuroma symptoms causing the sensation of a small electric shock, aroused by application of prosthesis, contact with bed, or on palpation. The mean visual analog scale (VAS) score for PLP was 8.4 (range 7 to 10) before neurectomy. The mean follow-up was 71.5 months (range 44 to 98 months).

RESULTS

Complete recovery from PLP was achieved after neurectomy. Symptoms of neuroma completely disappeared during the follow-up period. Visual analog scale score was 0 in all the patients.

CONCLUSION

The best way to prevent postamputation neuromas and PLP is to cut the nerve as proximal as possible, allowing its retraction into the soft tissue, and leaving its end away from the stump.

A case of tuberculous pyomyositis that caused a recurrent soft tissue lesion localized at the forearm

We present the case of a 20-year-old male who had a non-traumatic soft tissue lesion (4 x 3 cm) with recurrent discharge at his right posteromedial antebrachial muscles; the patient underwent surgery twice, and antibiotic therapy was administered, but no cure was achieved with these treatments. The patient underwent surgery at our medical center. There was no history of pulmonary, gastrointestinal, or genitourinary tuberculosis (TB). Due to suspected pulmonary, genitourinary, and gastrointestinal TB, radiography and computed tomography scans were performed, and these studies disclosed no evidence of a primary origin. The erythrocyte sedimentation rate and the results of purified protein derivate testing were normal. We also detected submandibular lymphadenopathy (LAP) (2 x 3 cm) localized at a submandibular site in our patient 4 months after his first visit to our clinic. Smears were stained with Ehrlich Ziehl Neelsen (EZN) stain and culture were grown for Mycobacterium tuberculosis complex (MTC); the samples used for these assays had been obtained by incisional biopsy of the forearm lesion and by aspiration of the submandibular lymph node, and they were found to be MTC-positive. Then, a culture for MTC, derived from an induced sputum sample, was found to be positive, despite the negative results obtained with a sputum smear subjected to EZN staining. According to these results, the primary focus of the tuberculous pyomyositis and the submandibular LAP was the lungs. The lesion and submandibular LAP were both treated successfully by the administration of antituberculous chemotherapy.

[Management of fibular hemimelia with the Ilizarov circular external fixator]

OBJECTIVES

We evaluated the results of treatment with the Ilizarov circular external fixator for limb length inequality and deformities in patients with type IA, IB, and type II fibular hemimelia.

METHODS

Tibial corticotomy and distraction osteogenesis with the Ilizarov technique were performed in five male patients (mean age 11.4 years; range 4 to 20 years). According to the classification of Achterman and Kalamchi, fibular hemimelia was type IA, IB, and II in three patients, one patient, and one patient, respectively. Involvement was on the right in three patients, and on the left in two patients. Two patients had equinus and one patient had valgus deformities. No instability existed in the ankle and knee joints. The mean leg discrepancy was 8.7 cm (range 3 to 16.5 cm), and the mean lengthening index was 1.6 cm/month (range 1.4 to 2 cm). The mean follow-up was 33 months (range 15 to 68 months).

RESULTS

On final examinations, full range of motion of the knee was obtained. A plantigrade foot was achieved in three feet, while two sustained an equinus deformity of 17 and 15 degrees, respectively. Pin tract infections were observed in four patients, all of which were treated with oral antibiotics and dressing. During distraction, three patients had pain. Two patients had a limited range of motion of the ankle joint, without instability or subluxation of the ankle and knee joints. These joint problems were successfully dealt with by physical exercises.

CONCLUSION

The Ilizarov technique is a convenient method in the correction of angular and rotational deformities while enabling distraction in type I and type II fibular hemimelia.

[Comparison between the distraction and grafting methods in the treatment of peripheral neural defects: an experimental study in rabbits]

OBJECTIVES

We compared the electrophysiologic and histopathologic results of grafting and distraction methods in the treatment of defective peripheral neural injuries.

METHODS

Thirty male white rabbits (age 6 months) were divided into three groups and a circular external fixator (CEF) was applied to the right tibias. In group I (primary repair), the right deep peroneal nerve was cut without inducing any defect and a tibial osteotomy was performed. The remaining groups underwent bone and nerve excision of about 1 cm in the middle third of the tibia. In group II, the defect area was closed acutely with the CEF and the continuity of the nerve was restored. In group III, a nerve graft obtained from the left side was placed in the defect area and an epiperineural repair was made. Group II underwent distraction 21 days after surgery for 10 days with a rate of 0.25 mm four times a day. Electrophysiological studies were performed in the 12th and 24th weeks and nerve biopsies were obtained in the 32nd week for histopathologic examination.

RESULTS

Electrophysiological studies in the 12th week did not show any significant differences in nerve conduction between the three groups; however, in the 24th week, amplitude and latency values of the graft group were 50% lower than those of the primary repair and distraction groups (p<0.05). On histological examination, the results were good in group I and II, but poor in group III with respect to nerve fiber density, thickness of the myelin sheath, degenerative changes in the myelin sheath, and average axon number.

CONCLUSION

Our data demonstrate that treatment of neural defects by the distraction method results in much better results than the grafting method.

Treatment of proximal fibular tumors with en bloc resection

Proximal fibular tumor resection has always been a challenge to an orthopedic surgeon due to the proximity of two major structures; the peroneal nerve and anterior tibial artery. Extra-articular resection of the proximal tibiofibular joint, sacrificing of peroneal nerve and split resection of lateral tibial wall are major points of debate. Malawer described two types of resection for aggressive benign and malignant tumors of the proximal fibula, type I for benign and type II for malignant tumors. Between 1992 and 2002, nine male patients with proximal fibula tumors were treated by en-bloc resection as described either by Malawer and or by one of two new resection techniques. Of the nine tumors, six were diagnosed as giant cell tumor (one of them recurrent), two as osteosarcoma and one as benign fibrous histiocytoma. The mean age of the patients was 23.6 (20-48) years. The mean follow up period was 42.8 months (15-117). There were no complications leading to a secondary surgical procedure+no local recurrence. Tumor volume was over 250 ml in two GCT cases, so the deep peroneal nerve was sacrificed to provide a wide margin. Iatrogenic peroneal nerve palsy developed in two patients. Late tendon transfers were performed for the management of drop foot. Our results indicate that if tumor is recurrent or has a large volume, wide resection (including deep peroneal nerve) should be done. Despite satisfactory tumor management, functional outcomes turned out to be variable, therefore precise ligament and muscle reconstruction is recommended.

Treatment of Periapical Inflammatory Lesion with the Combination of Platelet-Rich Plasma and Tricalcium Phosphate: A Case Report

Periapical surgery is an important treatment alternative in the presence of a periapical inflammatory lesion. To achieve optimal healing and regeneration of the bone, different bone substitutes or barrier membranes can be used after degranulation of the lesion. Tricalcium phosphate (TCP) graft material is one of these substitutes. Platelet Rich Plasma (PRP) preparation is a new biotechnology and can be used in many different surgical procedures. It consists of thrombocyte concentrates and high amounts of growth factors (GFs), especially platelet derived growth factor (PDGF), insulin-like growth factor (IGF-I) and transforming growth factor (TGF-beta), which are important in wound healing and regeneration. In this case report, use of platelet gel in conjunction with TCP in the treatment of periapical inflammatory lesion and the results of 12 months has been reported.

Treatment of close-range, low-velocity gunshot fractures of tibia and femur diaphysis with consecutive compression-distraction technique: a report of 11 cases

Lower extremity injuries secondary to close-range, low-velocity gunshot wounds are frequently seen in both civilian and military populations. A close-range, low-velocity injury produces high energy and often results in comminuted and complicated fractures with significant morbidity. In this study, four femoral, four tibial, and three combined tibia and fibular comminuted diaphyseal fractures secondary to close-range, low-velocity gunshot wounds in 11 military personnel were treated with debridement followed by compression-distraction lengthening using a circular external fixator frame. Fracture union was obtained in all without significant major complications. Fracture consolidation occurred at a mean of 3.5 months. At follow-up of 46.8 months, there were no delayed unions, nonunions, or malunions. Minor complications included four pin-tract infections and knee flexion limitation in two femur fractures. Osteomyelitis and deep soft tissue infection were not observed. This technique provided an alternative to casting, open reduction internal fixation, or intermedullary fixation with an acceptable complication rate.