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.

Synovial hemangiohamartoma presenting as knee pain, swelling and a soft tissue mass: a case report

Introduction

We present a case of a patient with juxtaarticular hemangiohamartoma with a synovial extension associated with hemorrhagic synovitis and recurrent spontaneous hemarthrosis.

Case presentation

A 21-year-old Caucasian woman was admitted to our hospital complaining of pain and swelling at her knee for 6 months. In the magnetic resonance imaging, T2-weighted and fat-suppressed scans revealed a mass with high signal intensity just posterior to the patellar tendon. We performed an excisional biopsy of the mass through an anterior longitudinal incision. Excised material included arterial and venous vascular structures, which were found to be spread among the fat, connective and peripheral nerve tissues microscopically.

Conclusion

Although hemangiohamartomas are not true neoplasms, they may cause knee pain, swelling and hemarthrosis that warrant surgical resection. This lesion, although rare, should be considered in the differential diagnosis, especially in teenagers and young adults.

Ulnar-sided pain due to extensor carpi ulnaris tendon subluxation: a case report

INTRODUCTION

We present the case of a patient with extensor carpi ulnaris tendon subluxation who was first treated for distal radioulnar joint sprain.

CASE PRESENTATION

A 25-year-old Caucasian man was seen at our policlinic one month after he had fallen on his outstretched hand. A diagnosis of extensor carpi ulnaris subluxation was made clinically but we also had the magnetic resonance imaging scan of the patient's wrist which displayed an increased signal on T2-weighted images consistent with inflammation around the extensor carpi ulnaris tendon. The extensor carpi ulnaris tendon was found to be dislocating during supination and relocating during pronation. The sheath was reconstructed using extensor retinaculum due to attenuation of subsheath.

CONCLUSION

There was no recurrent dislocation of the extensor carpi ulnaris tendon of the patient at his last follow up 12 months after the operation.

Suprascapular nerve block for the treatment of frozen shoulder

Aims:

The aim of our study was to compare the effects of suprascapular nerve block in patients with frozen shoulder and diabetes mellitus unresponsive to intraarticular steroid injections.

Settings and Design:

Ten patients without improvement of sign and symptoms after intraarticular injections were made a suprascapular nerve block.

Methods:

Pain levels and active range of movement of patients were recorded at initial attendance and after 1, 4, and 12 weeks. All patients’ simple pain scores, total pain scores, and range of motion of their shoulders were improved significantly after suprascapular nerve block.

Statistical Analysis:

In this study, the statistical analyses were performed by using the SPSS 8.0 program (SPSS Software, SPSS Inc., USA). To compare pre- and post-injection results of simple pain score, total pain score, shoulder abduction and external rotation, Wilcoxon test was used.

Results:

Patient's simple pain scores, total pain scores also abduction, external rotation and internal rotation angles were improved significantly after suprascapular nerve block.

Conclusion:

Effective results after suprascapular nerve blockage was obtained for the treatment of refractory frozen shoulder cases.

Closed total talar extrusion after ankle sprain

Closed total talus dislocation from tibiotalar, subtalar, and talonavicular joints is a very rare injury. A 25-year-old young man, who had severe ankle distortion while walking down a flight of stairs, was brought to the emergency room complaining of a deformity and pain in his ankle joint. Roentgenographies revealed total talar body extrusion. The patient was treated urgently with open reduction in the authors' clinic. Tibialis posterior tendon might prevent closed reduction so open reduction with retraction of the tendon may be necessary.

Mosaicplasty for the treatment of the osteochondral lesion in the femoral head

Osteochondral defects of the femoral head are rare and principles of treatment include anatomic reduction, rigid fixation, enhancement of blood supply, and restoration of articular congruity. In this report, we present a case where the defect of the femoral head was treated with surgical dislocation of hip anteriorly and mosaicplasty. At 3-year follow-up, the patient was symptom free with near complete incorporation of the graft radiographically. Our observations in this case suggest that mosaicplasty with an open approach is an alternative treatment in the osteochondral defects of the femoral head.

Effect of osteoporosis on clinical outcomes in intertrochanteric hip fractures treated with a proximal femoral nail

The effect of osteoporosis on clinical outcomes following surgical treatment of intertrochanteric hip fractures was investigated. A total of 80 patients aged 65-97 years with intertrochanteric hip fractures underwent insertion of a proximal femoral nail. Osteoporosis severity was measured using the Singh index in the unaffected hip. Screw cut-out occurred in four patients, reverse Z-effect in three patients and Z-effect in one patient. Four patients were lost to follow up. Clinical results were evaluated according to the Harris hip scoring system. The mean Harris hip score was 73.58 (range 25-100). When divided according to Singh index grade (I-II versus III-V), there were no significant differences in mean age, type of fracture, American Society of Anesthesiologists classification or frequency of technical failures between the two groups. The mean Harris hip score, however, was significantly lower in patients with grades I-II compared with grades III-V, suggesting that the presence of osteoporosis had a negative effect on clinical outcome after hip fracture.

Transverse incision for calcaneal tuberosity avulsion fractures

A number of incision options are available to surgeons approaching the posterior aspect of the calcaneus for repair of fractures of the posterosuperior aspect of the body of the calcaneus. In this brief communication, we depict our preference for the use of a transverse posterior calcaneal incision for reduction and fixation of avulsion fractures of the calcaneus. The advantages of this particular incisional approach include adequate exposure to the underlying target structures, orientation of the scar in line with relaxed skin tension lines, which minimizes scar formation, and avoidance of dissection of the Achilles tendon.

Midterm results of biologic fixation or mosaicplasty and drilling in osteochondritis dissecans

BACKGROUND

Osteochondritis dissecans (OCD) primarily affects subchondral bone. Multiple drilling, fixation implant or autogenous osteochondral grafts are reported as treatment options. We present the midterm results of cases in which an OCD lesion was treated by osteochondral autograft transfer and drilling.

MATERIALS AND METHODS

Between 2002 and 2006, 14 knees with International Cartilage Repair Society (ICRS-OCD) type II and III lesions were treated in our clinic using osteochondral autograft transfer and drilling by arthroscopic or open surgery. The average age of our patients was 22.14 years (range 17-29 years) and average followup was of 24.3 months (range 11-40 months). Lesion type was ICRS type II in five patients (35.7%) and ICRS type III in nine patients (64.3%). In cases with ICRS-OCD type II lesions, in situ fixation was applied following circumferential multiple drilling, while mosaicplasty was done following debridement and multiple drilling in cases with ICRS-OCD type III lesion. Mosaicplasty was performed in the lesion area by an average of 2.5 (range 1-3) cylindrical osteochondral autografts. Patients were not allowed to perform loading activities for 3 weeks in the postoperative period; movement was initiated by using CPM device in the early phase; full range of motion was achieved in third week, and full weight bearing was permitted in 6 to 8 weeks

RESULTS

While 6 and 8 patients were classified preoperatively as fair and poor, respectively, according to Hughston scale, excellent and good results were obtained postoperatively in 10 and 4 patients, respectively. During the followup, no problems were detected in any of the patients in the regions where osteochondral graft was harvested.

CONCLUSION

Biologic fixation or mosaicplasty and drilling as a technique to treatment of the lesion in OCD by osteochondral autograft transfer has resulted in good and excellent clinical outcomes in our patients and it is considered that providing blood flow to subchondral bone by circumferencial drilling leads to an increase in the robustness of biological internal fixation and shortens the duration of recovery.

Traumatic ipsilateral multiple open metatarsal and calcaneal fractures with first metatarsophalangeal joint dislocation: a case report

A 17-year-old man fell from a height of 10 m onto his right forefoot and sustained ipsilateral calcaneal, comminuted cuboid, and second, third, and fourth metatarsal neck fractures and first metatarsophalangeal joint open dislocation. This report discusses this rare injury. The authors believe that initial debridement with immediate surgical fixation and reduction with appropriate antibiotic treatment saved the patient's extremity.

Biomechanical comparison of plate-screw and screw fixation in medial tibial plateau fractures (Schatzker 4). A model study

INTRODUCTION

The objective of this biomechanical study was to compare the respective efficiency of plate-screw fixation and screw fixation in an experimental model of a Schatzker type 4 fracture.

HYPOTHESIS

screw fixation and plate fixation have a similar load to failure.

MATERIALS AND METHODS

This study compares the stability of Schatzker type 4 medial tibial plateau fractures fixed with either 36.5mm cancellous bone screw with a 16 mm threaded segment or with six-holed buttress T-plate-screw system. A Schatzker type 4 fracture was modeled on an artificial bone model. In a first group of 10 fracture models, following the anatomical reduction, fractures were stabilized with screws with washers. In the second group, of 10 fracture models, fractures were stabilized with T-plate. After fixation ascending axial compression was applied on bone models (Instron machine).

RESULTS

Load bearing capacity was 1397.6+/-194.4N in the Group 1 and 2153.2+/-204.4N in the Group 2. The difference between the two groups was statistically significant (p<0.001).

DISCUSSION

According to this result, experimental load bearing of bone models indicate that plate-screw fixation system has a significantly higher stabilization capacity than fixation with three screws alone. Our hypothesis was not confirmed. In order to maintain anatomical repositioning, plate-screw system is a more stable fixation method than the screw in medial tibial plateau fractures Schatzker 4 LEVEL OF EVIDENCE: 1.

Treatment of Tönnis type II hip dysplasia with or without open reduction in children older than 18 months: a preliminary report

PURPOSE

In this study, we aim to investigate whether the hip with Tönnis type II dysplasia in children older than 18 months can be treated without open reduction.

METHODS

In our study, 47 hips (47 patients) with type II developmental dysplasia of the hip according to the Tönnis classification were treated by a combination of open reduction through an anterolateral approach with iliopsoas tenotomy followed by innominate osteotomy and capsulorrhaphy or iliopsoas tenotomy followed by innominate osteotomy. The patients with open reduction constitute the open Salter group (32 hips), while the rest of the patients with innominate osteotomy alone constitute the closed Salter group (15 hips). The acetabular index (AI) and Smith's c-b and h-b index were assessed on the preoperative, immediate postoperative and final follow-up hip X-rays.

RESULTS

There were no statistically significant differences related to sex distribution, age and postoperative follow-up time between the patients of each group. There was also no statistically significant difference between the preoperative AI of the open and closed Salter osteotomy groups. Overall, 80% of hips with open reduction had Smith's c-b ratio greater than the value of 1 and h-b ratio lower than the value of 0.05.

CONCLUSION

The preoperative c-b index of the open osteotomy group was statistically greater than the c-b index of the closed osteotomy group and the preoperative h-b index of the open Salter group was statistically smaller than the h-b index of the closed Salter group, which means that most of the hips in the open osteotomy group are more in a lateralised and superior position compared to the closed osteotomy group. To us, there exists a subgroup of hips with less lateralisation and superior displacement according to the Smith's c-b and h-b ratio in Tönnis type II hip dysplasia. These hips might be less amenable to capsulorrhaphy because of the lower capsular instability and treatment may be done with closed reduction after iliopsoas tenotomy with Salter osteotomy in this select group of patients.

Arthroscopy-assisted combined external and internal fixation of a pilon fracture of the tibia

There are serious problems with existing methods of treating pilon fractures of the tibia caused by high-energy trauma. The method chosen to treat these fractures should not raise the risk of infection while effectively restoring the joint surface. We successfully treated a 42-year-old male patient with a pilon fracture caused by high-energy trauma using an arthroscopy-assisted unilateral external fixator and minimally invasive internal osteosynthesis. We used arthroscopy to reposition the fracture fragments and restore the joint surface. The fracture fragments were fixed with screws immediately after being repositioned. We believe that arthroscopy-assisted combined external and minimally invasive internal fixation is the treatment of choice for these fractures. We used external fixation to improve the fracture alignment, arthroscopy for restoring the joint surface, and minimally invasive screws to ensure fragment stability.

Second-look arthroscopy after arthroscopy-assisted treatment of tibial plateau fractures

The only way to show the healing potential in hyaline cartilage after the treatment of tibial plateau fractures in humans is the second-look arthroscopy. Our aim is to examine the healing potential of the hyaline cartilage in tibial plateau fractures treated with arthroscopy-assisted surgery. We applied second-look arthroscopy to the 12 patients out of 52 who had tibial plateau fractures treated by arthroscopy-assisted surgery. The mean age was 41. The tibial plateau fractures were classified according to Schatzker classification. The period between the primary surgical treatment and second-look arthroscopy was on an average of 19 months. Step-off was detected in 3 out of 12 patients. Hyaline cartilage of nine patients who did not have step-off was found obviously on the fracture line. None of them had displacement. Three patients out of 12 were above 50 years old and the average follow-up period was 26 months. Grade II-III chondral defect was detected on the fracture line and femoral condyle in patients above 50 years. For patients below 50 years old, the follow-up period was 21 months and grade I-II chondral defect was detected on the fracture line and femoral condyle. Until now in literature, tibial plateau fractures have been evaluated clinically and radiologically, but in our cases we directly saw the lesion. Cartilage healing is limited in human beings. On the fracture line, cartilage defect continues, although anatomic reduction has been achieved. Moreover, if there is step-off, insufficient healing potential appears. Although we did not have enough cases, we can say that in tibial plateau fractures anatomic reduction is mandatory. Contrary to the common idea, step-off is not tolerated by hyaline cartilage.

Is there a safe area for the axillary nerve in the deltoid muscle? A cadaveric study

BACKGROUND

Several authors have defined a variety of so-called safe zones for deltoid-splitting incisions. The first aim of the present study was to investigate the distance of the axillary nerve from the acromion and its relation to arm length. The second aim was to identify a safe area for the axillary nerve during surgical dissection of the deltoid muscle.

METHODS

Twenty-four shoulders of embalmed adult cadavers were included in the study. The distance from the anterior edge of the acromion to the course of the axillary nerve was measured and was recorded as the anterior distance. The same measurement from the posterior edge of the acromion to the course of the axillary nerve was made and was recorded as the posterior distance for each limb. Correlation analysis was performed between the arm length and the anterior distance and the posterior distance for each limb. The ratios between arm length and the anterior and posterior distances were calculated for each case and were recorded as an anterior index and a posterior index.

RESULTS

The average arm length was 30.40 cm. The average anterior distance was 6.08 cm, and the average posterior distance was 4.87 cm. There was a significant correlation between arm length and both anterior distance (r = 0.79, p < 0.001) and posterior distance (r = 0.61, p = 0.001). The axillary nerve was not found to lie at a constant distance from the acromion at every point along its course. The average anterior index was 0.20, and the average posterior index was 0.16.

CONCLUSIONS

The present study describes a safe area above the axillary nerve that is quadrangular in shape, with the length of the lateral edges being dependent on the individual's arm length. Using this safe area should provide a safe exposure for the axillary nerve during shoulder operations.