Self-inflicted tourniquet application resulted with two fasciotomies: Case report of an initially omitted Munchausen case.

INTRODUCTION: Compartment syndrome is an emergency which requires prompt intervention. While main challenge typically revolves around determining necessity for fasciotomy in suspected cases, etiology is often pronounced, leaving little room for differential diagnosis. CASE REPORT: We report a case with unconventional presentation and clinical course, ultimately diagnosed as Munchausen Syndrome. DISCUSSION: It has been reported that individuals with Munchausen syndrome are successful at manipulating healthcare professionals. They often study the symptoms of their sickness, examination findings, and findings that may alert doctors, mastering their techniques over time. CONCLUSION: It is of importance to consider Munchausen Syndrome as a potential cause, particularly in cases where clinical history and course of symptoms do not align with our experiences and cannot be reconciled with other possible diagnostic patterns.

Entrapment of median nerve after elbow fracture dislocations: expected surgical time frame based on cadaver study.

INTRODUCTION: Median nerve injuries occur in approximately 3% of pediatric elbow fracture dislocations. These rare injuries can be difficult to diagnose, and the results are poor in delay cases. Surgical timing is one of the most important prognostic factors. We aimed to present three patients with median nerve palsy who were referred to our clinic late, and according to these cases, we emphasized the expected time frame for exploration based on our anatomical cadaver study. MATERIALS AND METHODS: Between 2008 and 2010, three patients were referred to our clinic because of median nerve paralysis after a treated elbow dislocation. The mean interval between injury and referral was 15 (min: 13-max: 18) months, and the mean age of the patients was 15 (13-18) years. Neurolysis was performed in two patients, and for the third patent, after neurolysis, axonal continuity was observed to be disrupted so sural nerve grafting was performed with four cables. Tendon transfers were performed in all patients. A total number of 20 upper extremities of 10 cadavers were dissected. Due to its proximal innervation and ease of assessment, the muscle innervation of the flexor pollicis longus (FPL) was planned to be evaluated. The distance from the medial epicondyle is calculated in the cadaver study where the nerve injury is found. RESULTS: The mean length from the medial epicondyle to the motor innervation of FPL was calculated in each specimen and found to be 101.99 millimeters (mm) (range: 87.5-134.2). The mean longest innervation of FPL was 110.83 mm from (range 87.5-148.1) the medial epicondyle calculated by including each specimens longest nerve length. Knowing that the healing time of a nerve lesion is 1 mm per day, we calculated that the recovery of FPL would take approximately 4 months. CONCLUSION: When nerve healing is expected to be 1 mm a day in axonotmesis type injury, after the median nerve palsy following elbow dislocation, thumb flexion should be achieved in the following 4 months generally if the nerve was not entrapped in the joint. This cadaver-based study objectively defined how long to wait for the innervation of the FPL in median nerve injuries in elbow fracture dislocations.

Understanding the recurrent pulled elbow.

Nursemaid elbow is subluxation of the radius head seen in early childhood. The aim of this study was to examine the epidemiology of recurrent dislocations and the effect of hyperlaxity and bone anatomy on recurrent dislocations in these injuries, for which the pathogenesis has not been fully clarified. The study included a total of 329 paediatric patients who presented at the Paediatric Emergency Department (ED) between January 2016 and December 2022, and were diagnosed with Nursemaid Elbow. On presentation at ED, two-directional elbow radiographs were taken of all the patients and the radius head-neck ratio was measured on the lateral elbow radiograph. The Beighton score of joint hyperlaxity was evaluated in all the patients with a history of recurrent dislocation. A statistically significant difference was determined between the Beighton score groups in respect of the number of dislocations in multiple dislocations (P = 0.002). No statistically significant relationship was determined between the number of dislocations and the lateral radius head/neck ratio (P = 0.061). Hyperlaxity syndrome should be kept in mind in the aetiology of multiple dislocations.

Prospective Associations Between Fear of Falling, Anxiety, Depression, and Pain and Functional Outcomes Following Surgery for Intertrochanteric Hip Fracture.

Objective: Fear of falling, anxiety, depression, and pain levels are important risk factors for poor functional outcomes that may potentially be modifiable. We aimed to examine prospective associations between those factors following surgery for intertrochanteric hip fracture. Methods: This study is a prospective observational cohort study of patients aged over 65 diagnosed with isolated intertrochanteric hip fracture. Three hundred and seventy patients who underwent intramedullary fixation surgery were screened; 188 cases were included in our final evaluation. Patients with any concomitant fracture, major psychiatric/neurocognitive and neurological disorders and those with any other major disease were excluded from the study. Age, Charlson Comorbidity Index (CCI), Geriatric Depression Scale (GDS), State-Trait Anxiety Inventory (STAI), Falls Efficacy Scale International (FES-I), and Visual Analog Scale (VAS) scores on the day of surgery (baseline) were evaluated as predictors of poor/good outcome at 90 days after surgery, by Harris Hip Score (HHS) with a cut-off score of 70. Results: HHS score was significantly predicted at baseline by the full model [χ2 (7) = 18.18, P = .01]. However, only STAI-state scores were significantly added to the model [Exp (B) 95% CI: .92 (.86-.99)]. Conclusions: In this prospective cohort study, we found that higher levels of anxiety state on the day of surgery predicts a poor outcome at 90 days following surgery. We did not find significant associations between other variables, including age, GDS, STAI-trait, FES-I, VAS, and CCI. This potentially modifiable psychological factor may inform surgeons and could be a potential mediator. Future prospective studies are needed to replicate these findings. Level of evidence: Prognostic level I.

Nascent Malunion of Distal Radius Fractures Treated with Fixed Angled Volar Plates without Using Bone Grafts.

Purpose: Malunion of the distal radius is a common complication. Using bone grafts is common to restore the bone to an acceptable level. This study aimed to verify if it is necessary to use bone grafts in nascent malunion of distal radius fractures treated with fixed angled volar plates and which radiographic parameters are essential to obtain satisfactory outcomes. Methods: This single-centered prospective study included 11 patients who underwent corrective osteotomy of the radius for malunion. Patients with a metaphyseal, extraarticular osteotomy stabilized by a volar fixed angle plate within 3 months after the fracture are included. Patients underwent a standard radiological evaluation at postoperative 1 month, 3 months, 6 months, 1 year, and annually thereafter. Radial inclination, radial height, ulnar variance, and palmar tilt were measured. Wrist ranges of motion are measured throughout follow-up with a goniometer. Grip strength is measured using a Jamar Hand Dynamometer. The function is evaluated via the Gartland-Werley (GW) score and the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Results: The mean age of 11 patients, 9 (81.82%) males, included in the study was 41.45 ± 14.89 years. The mean post-fracture admission time is 39.3 ± 15.1 days. Radial inclination, radial length, and ulnar variance improved significantly after surgery (p = 0.0023, 0.0002, 0.0037). Radial inclination values are within normal limits for all patients at admission. The radial length was in the normal range for 72.73%, the ulnar variance was in the normal range for 72.73%, and palmar tilt was in the normal range for 100% of the patients. Extension 54.55%, flexion 72.73%, radial deviation 81.82%, ulnar deviation 63.64%, pronation 90.91%, and supination 72.73% were achieved after surgery. GW average was 3.09 ± 3.24 DASH score average was 12.24 ± 13.48. The mean grip strength was 29.27 ± 7.21 on the operated side, while it was 34.91 ± 5.32, on the healthy side, with a significant difference (p = 0.0108). Conclusion: It is possible to get good results without using bone grafts in corrective osteotomy of distal radius malunions.

Is biceps tenodesis necessary when performing arthroscopic rotator cuff repair in patients older than 55 years?

INTRODUCTION: In patients with arthroscopic rotator cuff repair, tenotomy and tenodesis are the most performed surgical procedures for the biceps long head (BLH) pathologies. Controversy continues as to which surgical procedure provides better results. This study aimed to compare the clinical outcomes of tenotomy and tenodesis applied to the biceps long head in patients who underwent arthroscopic rotator cuff repair. MATERIALS AND METHODS: In our study, the clinical results of 706 patients who underwent arthroscopic rotator cuff repair with tenotomy or tenodesis on the long biceps head were evaluated retrospectively. Rotator cuff repair patients were divided into two groups as single-row and double-row repair patients. The clinical results of patients who underwent tenotomy and tenodesis in single-row (n = 383) and double-row (n = 323) repair groups were compared. The clinical outcomes of the patients who underwent tenotomy and tenodesis without distinction between double/single-row repair were also compared. Preoperative and postoperative clinical evaluations of the patients were made with Constant Shoulder Score (CSS) and visual pain scale (VAS). The presence of the Popeye sign in the arm, tenderness in the bicipital groove, and cramping in the biceps muscle in the postoperative period was evaluated and compared among groups. Preoperative and postoperative clinical results of the patients were compared within the groups. RESULTS: A total of 706 patients with a mean age of 61.78 ± 20.94 years and a mean follow-up period of 29.15 ± 14.28 months were evaluated. The mean age of the tenodesis group (58.13 ± 8.47) was significantly lower than the tenotomy group (61.52 ± 22.58) (p < 0.05). The mean CSS and VAS mean postoperatively in the tenotomy group (n = 587) were 76.84 ± 12.74 and 2.29 ± 2.78. The postoperative mean CSS and VAS in the tenodesis group (n = 119) were 77.56 ± 11.23 and 2.64 ± 2.70. There was no statistically significant difference between the postoperative clinical scores of patients who underwent tenotomy and patients who underwent tenodesis (p > 0.05). There was no difference between the tenotomy and tenodesis groups regarding Popeye deformity (p = 0.980). Bicipital groove tenderness and cramping in the biceps muscle were significantly higher in the tenodesis group (p < 0.001, < 0.001). Tenodesis was performed in 68, and tenotomy was performed in 315 out of 383 patients who underwent single-row rotator cuff repair. Tenodesis was performed in 51, and tenotomy was performed in 272 of 334 patients who underwent double-row rotator cuff repair. When singe versus double-row groups was compared, there was no significant difference in VAS, CSS, Popeye sing, bicipital groove tenderness, or biceps muscle cramping. When tenotomy versus tenodesis was compared within single- and double-row repair groups, there was no significant difference in VAS or CSS. There was no difference between the tenotomy and tenodesis groups regarding Popeye deformity, but bicipital groove tenderness and muscle cramping were more in tenodesis groups regardless of the repair rows. CONCLUSIONS: The effect of tenodesis versus tenotomy for BHL pathologies in patients who underwent arthroscopic rotator cuff repair was not significant for clinical scores, but bicipital groove tenderness and biceps muscle cramping were significantly higher in the tenodesis group.

Anterolateral Thigh Flap Coverage for Large Posterior Defects of the Elbow.

Purpose: This study highlights the advantages and disadvantages of Anterolateral Thigh (ALT) free flap using the brachial artery as the recipient vessel in large posterior defects of the elbow with early mobilization. Methods: Eight patients with a soft tissue defect on the posterior elbow underwent reconstruction with an ALT free flap. Average age and follow-up were 29.5 years (range, 18-43 years) and 54 months (range, 35-76 months), respectively. All defects were on the posterior side, and brachial arteries on the anterior side were used as the recipient artery in all cases. Four defects were created by tumor excision, four were exposed with hardware after fixation of distal humeral and/or proximal ulna fractures. The dimensions of defects were between 80 and 352 cm2. Cases were evaluated according to function (ROM), complications, tissue quality anticipated from reconstruction and immobilization time after the reconstruction. Results: All flaps except one survived and met the tissue quality anticipated from this reconstruction. In the bigger flaps, an apparent ugly scar at the donor site was the main problem. The flap on the posterior, and recipient artery on the anterior had no adverse effects on early motion of the elbow. Two cases with fractures had minimal restriction of elbow movement due to post-traumatic stiff elbow. There was one case of partial flap loss after myocardial infarction. After the patient was medically stable, the remaining distal defect was closed with a pedicled radial forearm flap. Conclusion: ALT free flap has numerous advantages in covering defects at the posterior elbow such as being pliable, thin and durable skin, with a long and reliable pedicle reaching the brachial artery without causing any problem in early motion and surgical reconstruction can be easily completed in the supine position.

The Effect of Acromial Morphology on the Functional Outcomes of Degenerative Rotator Cuff Tear Surgery.

PURPOSE: The aim of this study was to investigate how the critical shoulder angle (CSA) and acromion index (AI) affect the outcome of arthroscopic rotator cuff tear (RCT) repair. METHODS: A total of 287 patients, who underwent arthroscopic surgery due to degenerative rotator cuff tear, were evaluated. The Constant Shoulder Score (CSS), Oxford Shoulder Score (OSS) and Visual Analogue Scale (VAS) were evaluated preoperatively and postoperatively. The AI and CSA were measured on true anteroposterior shoulder radiographs. The patients were separated into two groups according to their CSA and AI values (control group ≤ 38°, increased CSA > 38°, and control group ≤ 0.7, increased AI > 0.7). The relationship between CSS, OSS and VAS was examined in all the groups. RESULT: The evaluation was made of a total of 287 patients with a mean age of 60.29 ± 8.55 years. The mean duration of follow-up of the patients was 34.00 ± 18.97 months (range 12-80 months). There was a statistically significant difference between the preoperative and postoperative clinical scores of the patients (p < 0.05). No relationship was determined between CSA, AI and CSS, OSS or VAS during follow-up (p > 0.05). The interobserver ICC for CSA and AI were determined to be 0.962 and 0.967, respectively (95% CI) indicating a high correlation (p < 0.001). CONCLUSION: CSA and AI do not affect functional outcomes in the postoperative period, so they are not significant at the time of degenerative arthroscopic rotator cuff repair decisions.

Radiological maturation and clinical results of double-bundle and single-bundle anterior cruciate ligament reconstruction. A 5-year prospective case-controlled trial.

INTRODUCTION: The aim of the study was to make a prospective comparison of the radiological and clinical outcomes of patients undergoing single-bundle and double-bundle anterior cruciate ligament (ACL) reconstruction. METHOD: This prospective, case-controlled study included 65 patients, separated into 2 groups as 33 patients undergoing single bundle (SB), and 32 patients undergoing double bundle (DB) ACL reconstruction. The patients were evaluated clinically using the International Knee Documentation Committee (IKDC) and the Lysholm knee scores. Stability was evaluated with the KT-1000 Arthrometer Measurement, the Lachman and pivot shift tests. Magnetic resonance images (MRI) at 1 and 5 years postoperatively were evaluated by a musculoskeletal radiologist. All the operations were performed by a single surgeon and the clinical evaluations were made by an independent researcher. RESULTS: Evaluation was made of a total of 53 patients (SB: 28, DB: 25). No statistically significant difference was determined between the groups regarding the postoperative IKDC and Lysholm scores. The pivot shift tests were negative in the DB group and positive in two patients of the SB group. The Lachman test was negative in all the patients. No significant difference was determined between the groups. No statistically significant difference was determined between the two groups in respect of the arthrometer measurements. In the SB group, revision surgery was performed in two patients due to graft failure. No graft failure findings were determined in the DB group, and no statistically significant difference was determined between the groups in respect of graft failure. On the MRIs taken at 1 year postoperatively, the ACL was seen to be hyperintense in 16 patients in the DB group and 6 patients in the SB group (p = 0.004). On the 5-year MRIs, ACL hypointensity could not be seen in three patients of the SB group and two of the DB group, with no difference determined between the groups (p > 0.05). CONCLUSION: In the 5-year follow-up period, no difference was determined between patients undergoing SB ACL reconstruction and those undergoing DB ACL reconstruction regarding clinical scores, knee stability, and MRI findings, but graft maturation occurs later the patients undergoing DB reconstruction.

Effect of affective temperament on outcome of rotator cuff surgery.

INTRODUCTION: Although numerous risk factors have been described, the effects of temperament, which is defined as a risk factor for certain disorders, on the outcome of patients undergoing rotator cuff surgery have not been investigated. HYPOTHESIS: We investigated whether a relationship exists between affective temperament and the outcome of patients undergoing rotator cuff surgery. MATERIAL AND METHODS: The outcomes of 176 patients undergoing rotator cuff surgery were examined using the Oxford and Constant questionnaires as well as visual analog scale values preoperatively and postoperatively. Inclusion criteria were defined as 1) dissatisfaction with pain despite 6 months of nonoperative treatment; 2) rotator cuff defects with full-thickness, small- to large-sized defects; 3) presence of a single dominant temperament or nondominant temperament; 4) no history of a diagnosed psychiatric disorder; and 5) a minimum of greater than 1 year of follow-up after surgery. Exclusion criteria were 1) other comorbid shoulder pathology; 2) irreparable or partial rotator cuff rupture; 3) grade 3 retractions; 4) grade 3-4 fatty infiltration; 5) other comorbid diseases such as diabetes, thyroid disorders, or inflammatory diseases; 6) history of shoulder surgery; 7) infection of the shoulder joint; 8) neurologic deficit in muscles around the shoulder; 9) two or more dominant temperaments; and 10) history of acromioclavicular joint resection and/or biceps tenodesis with cuff repair. All patient temperaments were evaluated according to the Temperament Evaluation of Memphis, Pisa, Paris and San Diego auto questionnaire version. RESULTS: The mean follow-up time was 45.5 months. The outcomes of patients with depressive temperament were worse than of patients with a nondominant temperament. This situation was observed both preoperatively and postoperatively. However, a similar relationship between nondominant and anxious temperament groups was observed only postoperatively. CONCLUSION: We noticed that depressive and anxious temperaments had a negative effect on patient outcomes after rotator cuff surgery; however, nondominant temperaments had a positive effect on patient outcomes. LEVEL OF EVIDENCE: Level III; Retrospective Comparative Study.