A novel nerve transfer: The first palmar interosseous motor branch of the ulnar nerve to the recurrent motor branch of the median nerve.

INTRODUCTION: The recovery of recurrent motor branch of the median nerve might be delayed in high level median nerve injuries due to the long reinnervation distance. The aim of this study is to define a novel nerve transfer to restore the opposition and pinch. METHODS: Two fresh frozen hand cadavers were used for the study. The motor branch of the first palmar interosseous muscle of the ulnar nerve was identified and dissected. Thenar branch of the median nerve was dissected from its insertion site. The motor branch of the first palmar interosseous muscle of the ulnar nerve was transferred to the thenar motor branch of the median nerve. Axon counts were examined histopathologically. Clinically this nerve transfer was performed for two female patients with a high-level median nerve injury. Mehta opposition scores were 21 and 20, respectively and the results were satisfactory six months after the surgery. DISCUSSION: Although exploration and repair are recommended as the first treatment for median nerve injuries, the waiting time until the motor branch is reinnervated is critical in high level lesions. Nerve transfers become very important for fast recovery. CONCLUSIONS: This new nerve transfer proposal may be an important step in nerve transfer surgery.

Perforator artery repair in revascularization of extremity degloving injuries.

INTRODUCTION: This article aims to expand the microsurgical treatment options for extremity degloving injuries with perforator artery repairs of the specific degloved angiosomes in upper and lower extremity. METHODS: Fourteen perforator arteries were repaired in seven patients. Four of them had circumferential degloving and 3 of them have non circumferential degloving injury. All had repair of the perforator arteries of the specific degloved segments. Four patients had additional vein repairs but none of the patients had AV shunts. RESULTS: All perforators provided adequate arterial supply to their specific angiosomes with some necrotic areas in neighboring angiosomes. CONCLUSIONS: Perforator artery repair within the degloved tissues provides a direct arterial supply successfully even if one could not find an intact venous plexus.

The analysis of functional and radiographic outcomes of conservative treatment in patients with low lumbar burst fractures.

INTRODUCTION: Burst fractures of the low lumbar spine constitute approximately one percent of all lumbar fractures. There is still no consensus on the optimal treatment of low lumbar burst factures. We aimed to evaluate the functional and radiographic outcomes of conservative treatment in patients with low lumbar burst fracture. METHODS: 15 patients (11 males, 4 females; mean age 32±8) who had low lumbar spine burst fracture treated with a custom-moulded thoracolumbosacral orthosis (TLSO) with a thigh extension were enrolled. The mean follow-up period was 22±6 months. 14 patients were neurologically intact and one had isolated nerve root injury. There were 24% type A fractures and 76% type B fractures according to the Denis classification system. Functional outcomes were evaluated by using Oswestry Disability Index (ODI), Short-Form 36 (SF-36) and Visual Analogue Scale (VAS). Radiographic outcome was analyzed by measuring anterior vertebral height loss, kyphosis angle, amount of canal retropulsion. Functional and radiographic outcomes were reviewed initially and at 1, 3, 6, 12 months, and at the latest follow-up. Functional and radiographic improvements were analyzed statistically. RESULTS: The mean bracing period was 11.9±1.7 weeks. The mean initial ODI, SF-36, and VAS score of the patients was 78.3±9.6, 23.7±8.9, and 8.7±0.7, respectively. The mean ODI, SF-36, and VAS score of the patients at the final follow-up was 26.4±6.5, 68.1±11.2, and 2.8±1.7, respectively. The improvement in functional outcomes was measured to be significant (p<0.05 for ODI, SF-36 and VAS). The mean initial anterior vertebral height loss, kyphosis angle, amount of canal retropulsion was found to be 27.2%±9.6%, -6.8°±3.2°, 37.4%±10.2%, respectively. The mean anterior vertebral height loss, kyphosis angle, and amount of canal retropulsion at the final follow-up was 23.1%±.6.7%, -4.2°±2.4°, 19.6%±7.7%, respectively. Among the radiographic outcomes, only the amount of canal retropulsion improved statistically (p=0.042). CONCLUSION: Conservative treatment using a custom-moulded thoracolumbosacral orthosis with a thigh extension is a safe and effective method in patients with low lumbar spine burst fractures and can improve functional and radiographic outcomes.

Scaphoid nonunion treated with vascularised bone graft from dorsal radius.

INTRODUCTION: The main aim of this retrospective study was to present our experience on scaphoid nonunion treated with vascularised bone graft. METHODS: Between 2006 and 2012, 58 patients presenting with symptomatic scaphoid nonunion were eligible to participate in this study. Topography of the nonunion included 29 proximal, 25 waist and 4 distal scaphoid nonunions. Vascularised bone graft from distal dorsal radius was used in all cases which were stabilised with the headless cannulated compression screws. Scapholunate angles, Natrass carpal height ratio were evaluated pre and postoperatively. Range of motion of the affected side was compared to that of the contralateral side after the surgery. RESULTS: Radiographic union was achieved in 50, out of 58 cases with an average time of 9.9 weeks (range, 6-18 weeks). Out of all the non-united cases, four of them were in proximal, three in the waist and one was in distal scaphoid. In nine proximal nonunions treated by 4+5 ECA graft all but one were united. The mean follow up was 21.7 months (12-62 months). The flexion was 91.6%, the extension was 91.5%, the radial deviation was 81.2%, and the ulnar deviation was 89.5% compared to the other side. The grip strength was 93%. Preoperative DASH score was 61.5 diminishing to 28.7 postoperatively. There was no significant change in Natrass carpal height ratio but a slight improvement occurred in scapholunate angles both pre and postoperatively. CONCLUSION: Vascularised bone graft is a good solution for scaphoid nonunion to enhance the healing rate especially in the presence of avascular necrosis. Proximal pole nonunions, humpback deformity and smoking are important negative factors for scaphoid nonunion despite the use of a vascularised bone graft. A trapezoidal wedge graft is necessary for the volar type nonunions with humpback deformity. 1,2 ICSRA offer an advantage with its proximity to scaphoid in all nonunion locations. Nonetheless, 4+5 ECA graft is also a good solution for proximal nonunions.

Does timing matter in performing kyphoplasty? Acute versus chronic compression fractures.

The objective of this prospective consecutive cohort study was to compare the clinical outcomes, the radiographic outcomes and the complication rates of symptomatic acute (< 10 weeks) and chronic (> 16 weeks) osteoporotic vertebral compression fractures (VCFs) treated with kyphoplasty. Twenty-eight consecutive patients had 52 symptomatic osteoporotic VCFs treated with kyphoplasty; 5 of these patients were treated in two sessions. The Oswestry Disability Index (ODI) for back pain, a Visual Analog Scale for pain assessment, a patients' satisfaction scale, and medication usage served to evaluate the clinical outcomes. All these variables improved significantly in both groups, and more so in the acute group, but the difference was most often not significant. Vertebral height, local kyphosis angle, global sagittal alignment and dynamic fracture mobility significantly improved in both groups (except global sagittal alignment), and again more so in the acute group (except global sagittal alignment); the difference between groups was significant regarding radiological variables, except global sagittal alignment. Timing of kyphoplasty certainly matters, as the clinical and radiological outcomes were mostly better in acute fractures than in chronic fractures, which somehow responded satisfactorily. Controlled studies (kyphoplasty versus natural history) are needed to establish the real value of the procedure.

The treatment of Kienböck disease with vascularized bone graft from dorsal radius.

INTRODUCTION: Numerous surgical treatment options are proposed for the Kienböck disease but there has not been a consensus on the most appropriate method yet. The aim of this study is to present our experience and preliminary results of the use of vascularized bone graft from dorsal radius. MATERIALS AND METHODS: Second and third intercompartmental supraretinacular artery pedicled bone graft has been used to treat 11 patients with Kienböck disease between 2001 and 2006. The average follow-up period was 37 months (range 19-77 months). Pre- and post-operative range of motion, pain and grip strength, radiologic parameters such as carpal height ratio, Stahl index and scapholunate angle were evaluated. RESULTS: Eleven patients were composed of two stage II, one stage IIIA and eight stage IIIB patients according to Lichtmann classification. At the end of the observation period, five excellent, four good, one fair and one poor results were observed. There were no or little changes in carpal height ratio and Stahl index. Pain has diminished considerably. DISCUSSION: We believe that the treatment of Kienböck disease with vascularized bone graft from the dorsum of the radius has encouraging results and need no other additional procedures.

[The role of creating a biological membrane in expediting nerve regeneration for peripheral nerve repairs]. / Periferik sinir tamirinde biyolojik membranin sinir iyilesmesini hizlandirici etkisi.

OBJECTIVES: Nerve guidance channels are natural or synthetic tubular conduits used to bridge the gap between the nerve stumps. Creation of a biological membrane may be a simple and cheaper way to obtain a nerve guidance channel. The goal of this study was to examine the role of a biological membrane in expediting nerve regeneration. METHODS: Twenty adult male Wistar albino rats weighing 200 to 250 g were divided into two groups equal in number. All the animals underwent median nerve dissection to create a 5-mm gap. In the first group, the defect was repaired with a graft obtained from the contralateral median nerve, while in the second group, a silicon implant was sutured and anastomosed between the stumps. After five weeks, the silicon implant was removed and a nerve graft taken from the contralateral median nerve was anastomosed inside the neoformed biological membrane. Recovery of muscular function indicating nerve regeneration was assessed by the prehension test proposed by Bertelli and Mira. In both groups, measurements were started after five weeks of grafting and continued for 12 weeks. RESULTS: Rats in the second group exhibited an accelerated recovery and nerve regeneration compared to the first group. Nerve regeneration was completed at 10 weeks in the second group, whereas the recovery rate was 90.2% at 12 weeks in the first group (p<0.05). CONCLUSION: The use of autogenous grafts is still the gold standard in nerve repair. This biological membrane not only expedites nerve regeneration, but also facilitates surgery and reduces operating time because it requires small incisions at the two ends. Considering these advantages, it may prove to be a good alternative to other techniques.

[Extensor indicis proprius transfers for extensor pollicis longus ruptures secondary to rheumatoid arthritis]. / Romatoid artritte ekstansör pollisis longus kopmalari için ekstansör indisis proprius transferi.

OBJECTIVES: We evaluated the results of extensor indicis proprius (EIP) to extensor pollicis longus (EPL) transfers for EPL ruptures secondary to rheumatoid arthritis. METHODS: Twenty-four patients (7 males, 17 females; mean age 41 years; range 22 to 72 years) with rheumatoid arthritis underwent EIP to EPL transfer for 25 ruptures. The mean duration from rupture to surgery was 4.3 months (range 1.5 to 11 months). Functional assessment of the fingers was made using a specific EIP-EPL evaluation method developed by Lemmen et al. Pinch and grip strengths were measured. Range of motion of the metacarpophalangeal and interphalangeal joints of the thumb was compared with the normal side. Patient satisfaction was evaluated by a visual analog scale. The mean follow-up period was 6.2 years (range 4.7 to 7.9 years). RESULTS: Functional results were perfect in 14 fingers (56%), good in six fingers (24%), moderate in four fingers (16%), and poor in one finger (4%). The pinch and grip strengths were 86% and 92% of the uninvolved hand, respectively. The mean visual analog scale score was 74 (range 24 to 99). Compared to the uninvolved side, the range of motion of the thumb and index finger decreased by 23 degrees and 7 degrees , respectively, with a 9% loss of interphalangeal motion and a 17% loss of metacarpophalangeal motion in thumb extension. Independent extension of the index finger was possible in 21 hands. CONCLUSION: The results of EIP to EPL transfers are successful in ruptures secondary to rheumatoid arthritis.

[The modifed Eden-Lange procedure for paralysis of the trapezius muscle]. / Trapezius felcinde modifiye Eden-Lange prosedürü: Olgu sunumu.

Trapezius muscle paralysis results from injury to the spinal accessory nerve. Impairment in the trapezius muscle function may destabilize the muscle resulting in winged scapula. A 25-year-old university student who was active in sports had complaints of shoulder drop and pain on abduction. He had a three-year history of fall resulting in a scapular fracture for which he received conservative treatment. Physical examination showed asymmetry and drop of the right shoulder. Lateral scapular winging was apparent particularly above 90 degrees of abduction. Electromyography revealed isolated paralysis of the trapezius muscle. The patient underwent reconstruction with the modified Eden-Lange procedure. After a two-year follow-up, asymmetry in the shoulder decreased, there was no pain on active abduction, and the patient returned to active sports and was fully satisfied with the outcome.

Reconstruction of diabetic foot ulcers by lateral supramalleolar flap.

OBJECTIVE: To report a series of 8 diabetic patients in whom the reconstruction of large-sized defect of the foot was performed using lateral supramalleolar flap. METHODS: Coverage of the soft tissue defect was carried out by a lateral supramalleolar flap in 8 patients who had large-sized, non-healing ulcers at the Celal Bayar University, Department of Orthopedics and Traumatology, Manisa, Turkey, between 1998-2003. The mean age was 54 years. Preoperatively Doppler flowmeter evaluation was performed, and the ischemic index was calculated in all patients. RESULTS: The flaps survived except for one patient who had a large defect on the heel with low ischemic index. The average healing time of the ulcer region and recovery of regular walking status was 34 days. The average healing period of the donor site was 35 days. After the average follow-up period of 40 months, neither infection nor a recurrence of the ulcer was encountered. The major problem of the donor area was skin graft breakdown and its non-aesthetic appearance due to hypertrophic granulation tissue. CONCLUSION: The lateral supramalleolar flap is a reliable option for the reconstruction of large-sized diabetic ulcers involving the dorsal aspect of the foot. This can also be used in conjunction with local muscle flaps, such as abductor hallucis for covering deep and large heel defects when the sural neurocutaneous flap is contraindicated.

[Giant cell tumor at the wrist: a review of 23 cases]. / El bileginde dev hücreli tümör: yirmi üç olgunun incelenmesi.

OBJECTIVES: We evaluated patients who underwent surgical treatment for giant cell tumor of the wrist with regard to recurrence rates, factors influencing tumor recurrence, complications, and postoperative functional and emotional status of the patients. METHODS: The study included 23 patients (6 males, 17 females; mean age 31.6 years; range 12 to 74 years) who were treated surgically for giant cell tumor of the wrist. Grading, assessment of surgical margins, and functional evaluation were performed according to the Enneking's criteria. The effects of tumor volume, soft tissue extension, and selected surgical therapy on recurrence were investigated. Joint movements and stability, postoperative pain, presence of deformity, muscle strength, limitations in functional activities, and patient satisfaction were evaluated. The mean follow-up period was 6.7 years. RESULTS: Of all the patients, 69% had stage 2 and 23% had stage 3 tumors. There was no significant correlation between tumor volume and recurrence (p=0.22). Recurrences were observed in three (33%) of nine patients with soft tissue extension and in four (28.6%) of 14 patients without soft tissue extension. Recurrence rates were 33.3% in those who were treated by curettage alone (n=3), 50% with curettage and grafting (n=6), 50% with curettage and bone cement (n=2), and 16% in those who underwent wide excision (n=12). CONCLUSION: The most important factor influencing recurrence rate in giant cell tumors is the extent of surgical resection. At least marginal resection must be considered in patients with stage 2 and 3 lesions especially in cases with soft tissue extension. Adjunctive therapy should be added if curettage is considered.

[Thumb duplication: an analysis of 72 thumbs]. / Cift basparmak anomalisi: 72 olgunun degerlendirilmesi.

OBJECTIVES: The aim of this study was to evaluate patients who were operated on for a duplicated thumb. METHODS: Sixty-seven patients (41 females, 26 males; mean age 2.5 years; range 6 months to 20 years) underwent surgery for a total of 72 duplicated thumbs between 1982 and 2003. Five patients had bilateral involvement. The anomaly was on the right in 39 cases, and on the left in 33 cases. Clinical and radiographic evaluations were made according to the Wassel classification. The Bilhaut-Cloquet technique was used in 13 symmetrically duplicated thumbs, while simple excision of the unserviceable part was performed in the remaining. Patient satisfaction was assessed with the use of a visual analog scale after a mean follow-up period of 3.6 years (range 1 to 10 years). RESULTS: Nail deformity was present in all cases treated by the Bilhaut-Cloquet technique. These thumbs did not exhibit growth retardation, but interphalangeal joint motion was limited in five, while seven had a larger size compared to the normal side. Limited range of motion was detected in eight cases (11.9%), affecting the metacarpophalangeal joint in one, and the interphalangeal joint in the others. Seventeen patients (25.4%) developed an angulation of more than 10 degrees in the alignment of the thumb. Secondary procedures were necessary in 25 cases (37.3%), including collateral ligament reconstruction (n=12; 17.9%), tendon rerouting (n=3; 4.5%), corrective osteotomy (n=5; 7.5%), and arthrodesis of the interphalangeal joint (n=5; 7.5%). Patient satisfaction with the surgical outcome was 85% (n=57). CONCLUSION: It is important to evaluate and treat the skin, nail, bone, and the ligaments in a simultaneous manner in order to obtain a good reconstruction and to decrease both the complications and the need for subsequent operations.

[Free radial forearm flap transfer for the reconstruction of the Achilles tendon and soft tissue defect: a case report]. / Asil tendon ve yumusak doku defektinin rekonstrüksiyonunda serbest radial önkol flep transferi: Olgu Sunumu.

Reconstruction of the soft tissue defects around the Achilles tendon is a difficult challenge. This condition traditionally has been treated with staged procedures. We report a case treated with a one stage procedure. A neuromusculocutaneous radial forearm free flap was used for the reconstruction of an achilles tendon and for covering the overlying large soft tissue defect caused by a gun shot injury. The defect on the Achilles tendon was 15 cm in length and soft tissue loss was 18 x 10 cm. The flap including flexor carpi radialis muscle tendon was applied over the Achilles tendon. A terminolateral arterial anostomosis was performed on the tibialis posterior artery. There was no complication except a mild superficial infection on the lateral side of the flap treated by antibiotherapy. A satisfactory functional result was obtained. Application of a free neuromusculocutaneous radial forearm composite flap is a good technique to cover achilles tendon and soft tissue defects and to restore the function as a one stage procedure.

[Giant-cell tumors of the tendon sheath involving the hand or the wrist: an analysis of 141 patients]. / El ve el bileginde tendon kilifinin dev hücreli tümörü: 141 hastanin degerlendirilmesi.

OBJECTIVES: Giant-cell tumors of the tendon sheath localized in the hand or wrist were retrospectively reviewed with respect to diagnosis, surgical treatment, and postoperative complications. METHODS: During a 21-year period, a total of 141 patients (83 females, 58 males; mean age 37.5 years; range 6 to 77 years) underwent surgery for 146 lesions that developed in the hand (n=134) or the wrist (n=12). Involvement was on the right side in 77 patients, and on the left side in 64 patients. The mean follow-up period was 3.5 years (range 6 months to 11 years). RESULTS: On presentation, the most common symptom was the presence of a painless soft tissue mass. The most frequent localization was the volar part (76%) of the second (27%) and the third (24) fingers, or the proximal phalanx (57%). Forty per cent of tumors were encountered at ages between 30 and 50 years. The duration of symptoms ranged from one month to five years and the highest number of presentations fell within the first six months. In eighteen patients, radiologic studies showed osseous involvement, being cortical sclerosis in 12 patients, and erosion in eight patients. Postoperative complications included digital nerve injuries in four patients, superficial infection in three patients, and joint stiffness in 12 patients. Twenty-three patients (16%) developed recurrences within a mean of 3.7 years (range 2 months to 7 years). CONCLUSION: Taking high rates of recurrences into consideration, surgery for giant-cell tumors of the tendon sheath requires wide surgical exposure, attentive skills, and the use of magnification.

Arthroscopic removal of the osteoid osteoma on the neck of the talus.

Juxta-articular osteoid osteomas arising around the ankle are unusual. Tumors arising on the neck of the talus will commonly produce symptoms mimicking monoarticular arthritis or trauma. Patients are usually treated for arthritis or ankle sprain, which often leads to a delay in definitive diagnosis. We present an arthroscopic removal of an osteoid osteoma on the neck of talus, and review the literature.

[Long-term results of autograft and allograft applications in hand enchondromas]. / El yerlesimli enkondromlarin tedavisinde otogreft veya allogreft uygulamalarinin geç dönem sonuçlari.

OBJECTIVES: We evaluated the long-term results of treatment with curettage followed by an autograft or allograft application in patients with enchondroma of the hand. METHODS: Within a 15-year period, 76 patients (41 males, 35 females; mean age 32 years; range 14 to 47 years) were operated on for enchondroma of the hand. Following curettage of the lesion, reconstruction of the defect was made either by an autograft obtained from the iliac crest (n=76) or by a dehydrated cancellous allograft (n=15). The diagnosis was histologically confirmed in all the cases. Functional and radiographic results were assessed according to the Enneking scoring system and the Tordai classification system, respectively. The mean follow-up periods were 13.5 years (10-22 years) and 7.4 years (6-11 years) in autograft and allograft applications, respectively. RESULTS: Consolidation of the autografts took a mean of 38 days and maximum grasp force was obtained in a mean of 46 days. These periods were 51 and 55 days, respectively, for the allografts. Functional results were excellent/very good in 64%, good in 23%, and poor in 13.1% with autografts; radiographically, 78.7% of the patients were in group I, 18% were in group II, and 3.3% were in group III. Of the allograft group, the results were excellent/very good in 66.7%, good in 26.7%, and poor in 6.7%. Radiographically, 80%, 13.3%, and 6.7% of the patients were classified in group I, II, and III, respectively. There were two recurrences in the autograft group, while one patient, in the allograft group, who had multiple enchondromatosis required a ray amputation because of malignant transformation. CONCLUSION: Autograft and allograft applications seem to yield similar success rates in the treatment of enchondroma of the hand.

[Glomus tumors of the finger: a report on 60 cases]. / Parmak yerlesimli glomus tümörü: 60 olgunun incelenmesi.

OBJECTIVES: We evaluated patients who underwent surgery for glomus tumors of the finger. METHODS: During a 23-year period, 60 patients (48 females, 12 males; mean age 34.6 years; range 5 to 60 years) underwent surgery for glomus tumors of the finger. The patients were evaluated with respect to symptoms on presentation, diagnosis, operation types, and postoperative complications. The mean follow-up was 16 months (range 6 to 72 months). RESULTS: The most common symptom was pain (67%), which intensified when exposed to cold in 42%. Other symptoms included tenderness in 37 patients (62%), swelling in the finger tip in six patients (10%), and nail deformities in 34 patients (57%). The tumors were most frequently encountered in the fourth and fifth decades of age. Localization of the tumor was in the right hand in 32 patients (53.3%), and in the left hand in 28 patients (46.7%). The time to surgery from the onset of symptoms ranged from six months to 30 years (mean 6 years). Fifty-one patients were examined by plain radiographs, 27 of which showed concave-surface erosions in the bone; nine patients underwent magnetic resonance imaging studies besides plain radiography. The tumors were subungual in 49 patients (82%) and in the pulp in 11 patients (18%), for which transungual and midlateral approaches were applied, respectively. Postoperatively, nine patients (15%) developed recurrences, all of whom achieved clinical recovery following a subsequent operation. CONCLUSION: Given the considerably delayed time to diagnosis, glomus tumors should be taken into consideration in the presence of severe finger tip pain of unknown origin.