The Turkish League Against Rheumatism Recommendations for the Management of Hand Osteoarthritis Under Guidance of the Current Literature and 2018 European League Against Rheumatism Recommendations.

OBJECTIVES: This study aims to explore the accordance to the 2018 European League Against Rheumatism (EULAR) recommendations for the management of hand osteoarthritis (OA) among the Turkish League Against Rheumatism (TLAR) expert panel and composition of TLAR recommendations for the management of hand OA under guidance of the current literature. MATERIALS AND METHODS: The TLAR convener designated an expert panel of 10 physicians experienced in hand OA for this process. The 2018 EULAR recommendations for the management of hand OA and the systematic review of the literature were sent to the expert panel via e-mails. The e-mail process which included Delphi round surveys was completed. The EULAR standard operational procedure Appraisal of Guidelines for Research and Evaluation II was followed. The level of agreement was calculated for each item and presented as mean, standard deviations, minimum and maximum and comparisons of 2018 EULAR recommendations were performed. RESULTS: Five overarching principles and 10 recommendations were discussed. Revisions were held for the sixth, seventh, and ninth recommendations with lowest level of agreements. These recommendations were revised in accordance with suggestions from the experts and re-voted. The revised forms were approved despite the lack of statistically significant difference between these forms (p=0.400, p=0.451, p=0.496, respectively). Except for the ninth recommendation about surgery (p=0.008), no significant difference in level of agreements was observed between the EULAR and TLAR hand OA recommendations. The 11th recommendation about paraffin bath was added. CONCLUSION: The optimal treatment of hand OA consists of personalized non-pharmacological (self-management, exercise, splint), pharmacological (topical non-steroidal anti-inflammatory drugs as the first choice), and interventional procedures (only for refractory cases) based on shared decision between the patient and physician. TLAR hand OA recommendations were created mainly based on the most recent literature and the last EULAR hand OA management recommendations, which are widely approved among the TLAR experts.

Efficacy of Pie-Crusting Technique on Soft Tissues in Distal Tibia and Fibula Fractures.

Distal tibia and fibula fractures are challenging injuries to treat as evidenced by the high rates of wound complications because of vulnerable soft tissue coverage. The aim of this study was to examine the effect on soft tissue complications of the pie-crusting technique when applied between 2 incisions in distal tibia and fibula fractures treated with open reduction and internal fixation. We reviewed 34 patients with distal tibia and fibula fractures treated between September 2014 and March 2017. The pie-crusting technique was performed during wound closure in 16 (47.06%) fractures (group 1) and classic wound closure was done in 18 (52.94%) fractures (group 2). The primary outcome was evaluated as the presence or absence of soft tissue complications such as superficial skin necrosis, deep skin necrosis, and deep infection. The mean age was 50.44 ± 13.51 (range 23 to 65) years in group 1 and 51.67 ± 14.49 (range 18 to 68) years in group 2. The mean follow-up time was 27.35 ± 9.02 (range 16 to 46) months. The mean surgery time after injury was 5.88 ± 3.5 (range 1 to 14) days in group 1 and 7.32 ± 4.25 (range 1 to 16) days in group 2. No soft tissue complications were seen in any patient in group 1. Five (27.77%) occurrences of superficial skin necrosis were observed in group 2. In 2 (11.11%) patients in group 2, deep necrosis and wound dehiscence occurred, and subsequent deep infection developed in 1 (5.55%) of these patients. The overall complication rate was higher in group 2 (p = .005). We believe that the pie-crusting technique is beneficial for wound closure in distal tibia and fibula fractures, because it reduces the tension of the skin and allows leakage of subcutaneous fluids.

Outcomes of primary surgical repair of zone 2 dDigital nerve injury.

The objective of our study was to assess the functional and sensory outcomes of the primary repair of 138 digital nerve injuries in 48 consecutive patients between January 2012 and November 2014, and to determine whether there were any relationships between demographics, clinical characteristics, or functional test results and post-operative sensory recovery outcomes. Mean follow-up was 14 (range, 10 to 20) months. Sensory evaluation was performed using the static two-point discrimination test, and post-operative sensoryrecovery results were classified according to the Seddon Classification: 69 (50%) injuries were S3+, 3 (2%) were S3, 15 (11%) were S2, 18 (13%) were S1, and 33 (24%) were S0. Sensory recovery was associated with time between surgery and testing and with objective functional recovery. More than half of digits sustaining nerve injuries had good intermediate-term recovery of sensation after early primary surgical repair. Surgeon experience and early primary repair may have a favorable impact on results.

The Effects of Electrocautery on Peripheral Nerve: An Experimental Study.

BACKGROUND The aim of this study was to assess the usability of an electrocautery device as nerve stimulator and to investigate histopathologically the adverse effects of electrocautery at low power on rat sciatic nerves. METHODS A total of 36 female Sprague-Dawley albino rats were divided into six groups according to the power applied to their sciatic nerves (1, 2, 3, 4, 5 and 6 W, respectively). Pathologic changes were studied by microscopic examination and scored (no change = 0, mild = 1, moderate = 2, severe = 3). Multiple comparisons were provided for all groups by the Bonferroni test (one-way analysis of variance). A p value < 0.05 was accepted as statistically significant. RESULTS The average scores were 2.66 ± 0.51, 3.66 ± 0.51, 5.83 ± 1.83, 10.0 ± 1.78, 11.0 ± 1.54, and 13.8 ± 0.89 in groups 1 to 6, respectively. Significant differences were found between all groups (p < 0.01), except between groups 1 and 2, groups 2 and 3, and groups 4 and 5 (p > 0.05) Variable motor responses and foot deformities were observed at the different power levels. CONCLUSION Although electrocautery devices provoke motor responses if getting in contact with peripheral nerves as do nerve stimulators, their use induces histopathologically adverse effects even at the lowest power. Their use around peripheral nerves should be avoided.

Extension Block Pinning Versus Hook Plate Fixation for Treatment of Mallet Fractures.

PURPOSE: To compare the outcomes and associated costs of the treatment of mallet fractures with either extension block pinning or open reduction and hook plate fixation. METHODS: We treated 22 patients for a mallet fracture that involved at least 25% of the distal phalanx articular surface. Three joints demonstrated concomitant volar subluxation. Extension block pinning was used to treat 16 fractures (group 1) and 6 were treated with open reduction and hook plate fixation (group 2). All patients were evaluated at the second, fourth, and sixth weeks after surgery. Collected data included range of motion, extensor lag, and pain status. Patients were asked to grade preoperative and postoperative pain levels on a visual analog scale. Functional outcomes were determined by Crawford criteria. We retrospectively performed a cost analysis using our institutional records. RESULTS: Mean follow-up was 12.7 months. Visual analog scale pain scores improved by a similar amount for both groups. Preoperative pain scores were 7.0 for group 1 and 7.5 for group 2. Postoperative levels were 2.0 and 2.0, respectively. Mean extensor lag was identical for both groups, 5°. Mean flexion was 70° for group 1 and 80° for group 2. Based on the Crawford criteria, group 1 had 5 patients rated as excellent, 6 as good, 3 as fair, and 2 as poor. Group 2 outcomes were 2 excellent, 2 good, and 2 fair. Five complications occurred in group 1, and 1 in group 2. Differences noted between groups were not statistically significant. Extension block pinning was more cost-effective than hook plate fixation. CONCLUSIONS: We find extension block pinning to be an equally effective but more cost-efficient treatment than open reduction and hook plate fixation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Treatment of osteonecrosis of the femoral head with focal anatomic-resurfacing implantation (HemiCAP): preliminary results of an alternative option.

BACKGROUND: The optimal treatment of osteonecrosis of the femoral head has not been established yet. The aim of this study was to report preliminary clinical results of focal anatomic-resurfacing implantation for the treatment of osteonecrosis of the femoral head. METHODS: Five patients (four male, one female) with seven surgical procedures, ages between 37 and 52 with an average age of 45.2 (+/- 7.2), diagnosed as femoral head avascular necrosis and who were unresponsive to conservative management or had failed previous surgical treatments were treated with a focal anatomic femoral head resurfacing between the years 2011-2012 and were retrospectively reviewed. Five patients with at least two years of follow-up, one left hip, two right hips, and two patients with bilateral hip surgery were included in this review. After safe surgical dislocation of the hip, full exposure of the femoral head was established. A focal-resurfacing implant matching patient anatomy and femoral head curvature was performed accordingly. Neither intraoperative or postoperative complications nor revision ensued. Visual analogue scores and Harris Hip Scores were recorded both preoperatively and at postoperative 2 years for all seven surgeries. RESULTS: The mean follow-up period was 26.6 +/- 3.8 months, with a range between 24-33 months. The mean visual analogue scores were 8.9 +/- 0.9 preoperatively and 2.3 +/- 1.0 postoperatively at year two (p = 0.017). Harris Hip Scores at postoperative follow-up were found to improve significantly from good to excellent scores (86.0 +/- 7.9), compared with preoperative poor scores (26.7 +/- 11.8) (p = 0.018). The clinical improvements in visual analogue scores (VAS) and Harris Hip Scores were also found to correlate with each other (p < 0.05). CONCLUSIONS: In the present study, the alternative technique of focal anatomic hip resurfacing with HemiCAP® yielded preliminary successful results for the treatment of osteonecrosis of the femoral head. To the best of our knowledge, this is the first case series in the literature, reporting functional clinical results with the use of a focal anatomic-resurfacing implant for the treatment of focal femoral head osteonecrosis.

The biomechanical and histological effects of platelet-rich plasma on fracture healing.

PURPOSE: Platelet-rich plasma (PRP) includes growth factors and proteins that accelerate and stimulate bone regeneration and tissue recovery. The aim of this study was to evaluate the effects of PRP on fracture healing in terms of biomechanics and histology. METHODS: Seventy female rats were included in this experimental study. They were divided into three groups: Group I (no PRP, n = 30), Group II (PRP added, n = 30) and Group III (control, n = 10). The left femurs of the rats in Groups I and II were osteotomized and fixed by K-wires. Although no additional intervention was performed on Group I rats, PRP was applied to the fracture sites of Group II rats. The remaining ten rats were used as the control group of the biomechanical test (Group III). In the fourth week, nine femurs from Group I and ten femurs from Group II, and in the ninth week, nine femurs from each group were removed, and bone recovery was assessed histologically according to Modified Lane-Sandhu histological scoring criteria. Three-point bending test was applied to femurs for biomechanical evaluation in the ninth week. RESULTS: Histological healing was found to be significantly higher in Group II than in Group I (p < 0.05). Furthermore, biomechanical test results showed that healing quantity and bone strength were significantly better in Group II than in Group I (p < 0.05). CONCLUSION: PRP is a widely studied material in the physiology of fracture healing. The results of this study demonstrated the ameliorative biomechanical effects of PRP on fracture healing, in addition to accelerating the histological union of fractures. In the light of these results, PRP could be a viable alternative to accelerate the healing of fractures, late unions or non-unions. LEVEL OF EVIDENCE: Prospective comparative study, Level II.

Triggering of the Digits After Carpal Tunnel Surgery.

INTRODUCTION: Carpal tunnel syndrome (CTS) and trigger finger may be seen simultaneously in the same hand. The development of trigger finger in patients undergoing CTS surgery is not rare, but the relationship between these conditions has not been fully established. The aims of this prospective randomized study were to investigate the incidence of trigger finger in patient groups undergoing transverse carpal ligament releasing (TCL) or TCL together with distal forearm fascia releasing and to identify other factors that may have an effect of these conditions. MATERIALS AND METHOD: This prospective randomized study evaluated 159 hands of 113 patients for whom CTS surgery was planned. The patients were separated into 2 groups: group 1 (79 hands of 57 patients) undergoing TCL releasing only and group 2 (80 hands of 56 patients) undergoing TCL and distal forearm fascia releasing together. The age and gender of the patients, dominant hand, physical examination findings, visual analogue scale (VAS), and electromyography (EMG) results were recorded. Follow-up examinations were made at 1, 3, 6, 12, and 24 months for all patients. We noted development of trigger finger in the surgical groups, and its location and response to treatment. RESULTS: The incidence of trigger finger development was statistically significantly different between group 1 and group 2 (13.9% and 31.3%, respectively). The logistic regression analysis of factors affecting the development of trigger finger posttreatment found that the surgical method and severity of EMG were significant, whereas the effects of the other factors studied were not found to have any statistical significance. CONCLUSION: There was an increased risk of postoperative trigger finger development in patients undergoing TCL and distal forearm fascia releasing surgery for CTS compared to those undergoing CTL only. There is a need for further studies to support this result and further explain the etiology.

Stewart Treves Syndrome: A Case Report.

Angiosarcomas are malignant tumors, which originate from the vessel endothelium and resemble the vessel structure. Stewart-Treves syndrome is an angiosarcoma which in general, develops in female patients after mastectomy and axillary lymph node dissection and is associated with chronic lymphedema. The prognosis of this rare complication is very poor. We present the case of a 52-year-old female who had undergone mastectomy due to breast cancer and 13 years later required shoulder disarticulation due to Stewart-Treves syndrome.

Transverse carpal ligament and forearm fascia release for the treatment of carpal tunnel syndrome change the entrance angle of flexor tendons to the A1 pulley: the relationship between carpal tunnel surgery and trigger finger occurrence.

PURPOSE: The appearance of trigger finger after decompression of the carpal tunnel without a preexisting symptom has been reported in a few articles. Although, the cause is not clear yet, the loss of pulley action of the transverse carpal ligament has been accused mostly. In this study, we planned a biomechanical approach to fresh cadavers. METHODS: The study was performed on 10 fresh amputees of the arm. The angles were measured with (1) the transverse carpal ligament and the distal forearm fascia intact, (2) only the transverse carpal ligament incised, (3) the distal forearm fascia incised to the point 3 cm proximal from the most proximal part of the transverse carpal ligament in addition to the transverse carpal ligament. The changes between the angles produced at all three conditions were compared to each other. RESULTS: We saw that the entrance angle increased in all of five fingers in an increasing manner from procedure 1 to 3, and it was seen that the maximal increase is detected in the middle finger from procedure 1 to procedure 2 and the minimal increase is detected in little finger. DISCUSSION: Our results support that transverse carpal ligament and forearm fascia release may be a predisposing factor for the development of trigger finger by the effect of changing the enterance angle to the A1 pulley and consequently increase the friction in this anatomic area. CLINICAL RELEVANCE: This study is a cadaveric study which is directly investigating the effect of a transverse carpal ligament release on the enterance angle of flexor tendons to A1 pulleys in the hand.

Tendon interposition and ligament reconstruction with ECRL tendon in the late stages of Kienböck's disease: a cadaver study.

BACKGROUND: The optimal surgical treatment for Kienböck's disease with stages IIIB and IV remains controversial. A cadaver study was carried out to evaluate the use of coiled extensor carpi radialis longus tendon for tendon interposition and a strip obtained from the same tendon for ligament reconstruction in the late stages of Kienböck's disease. METHODS: Coiled extensor carpi radialis longus tendon was used to fill the cavity of the excised lunate, and a strip obtained from this tendon was sutured onto itself after passing through the scaphoid and the triquetrum acting as a ligament to preserve proximal row integrity. Biomechanical tests were carried out in order to evaluate this new ligamentous reconstruction. RESULTS: It was biomechanically confirmed that the procedure was effective against axial compression and distributed the upcoming mechanical stress to the distal row. CONCLUSION: Extensor carpi radialis longus tendon has not been used for tendon interposition and ligament reconstruction in the treatment of this disease before. In view of the biomechanical data, the procedure seems to be effective for the stabilization of scaphoid and carpal bones.

Formation of osteocartilaginous exostosis resulting from the raising of a lateral supramalleolar flap.

An osteocartilaginous exostosis developed in a 4-year-old boy in whom a distally-based lateral supramalleolar adipofascial flap had been used to cover a defect in the dorsum of the foot. The bony exostosis was first noticed four months after the operation. It was excised with no complications and there has been no recurrence after two years follow-up. The exostosis was thought to result from stripping the perichondrium over the epiphyseal plate while the flap was being raised. This unique complication has not to our knowledge been reported after harvest of a flap before.

Is the rabbit knee a suitable model for the human interphalangeal and metacarphophalangeal joints of the hand?

OBJECTIVES: The purpose of this study was to assess the suitability of the rabbit knee as a small joint model for the human interphalangeal and metacarphophalangeal joints of the hand. METHODS: The proximal joint surface areas of 47 middle phalanges, the proximal and distal joint surface areas of 90 proximal phalanges, and the distal joint surface areas of 42 metacarpals of various human cadavers were calculated and compared with the distal femoral and proximal tibial joint surface areas of 20 knee of 10 New Zealand white rabbits by a photogrammetric method. RESULTS: The mean joint surface area of the rabbit proximal tibia was larger than the proximal joint surface area of the middle phalanx, the distal joint surface area of the proximal phalanx, the proximal joint surface area of the proximal phalanx, and the distal joint surface area of the metacarpal. The mean joint surface area of the rabbit distal femur was larger than that of the middle phalanx, but similar to the proximal joint surface area of the proximal phalanx, and that of the distal metacarpal and distal proximal phalanx. CONCLUSION: The rabbit knee is not suitable model for the human interphalangeal and metacarphophalangeal joints of the hand. There is still a lack of an appropriate animal model for the small joints of the hand.

Digital neuropathy of the median and ulnar nerves caused by Dupuytren's contracture: Case report.

INTRODUCTION: Digital neuropathy is a pure sensory neuropathy of a digital nerve. It may be caused by acute or chronic local trauma or pressure, or accompany systemic illnesses such as rheumatoid disease, leprosy, Raynaud disease, dysproteinemia, or diabetes mellitus. We describe an extraordinary case of digital neuropathy of the median and ulnar nerves caused by Dupuytren contracture. CASE REPORT: A 56-year-old right-handed man was presented with numbness and tingling of the little finger of the right and ring finger of the left hand. The clinical and EMG findings in this patient were consistent with a lesion of the median and ulnar palmar digital nerves of the right and left ring and little fingers. CONCLUSION: Dupuytren tissue usually affects the palmar fascia, superficial to the digital nerves, and it may rarely affect the spiral cord in the digits. A spiral cord may cause sensory loss due to impingement of digital nerves or Dupuytren tissue may have been compressing the palmar digital nerves against the relatively inelastic deep transverse metacarpal ligament. As a result, digital neuropathy can develop in those with Dupuytren's contracture, and nerve conduction studies should also be performed to determine the condition. New studies are needed to provide better diagnostic criteria for the condition.

A case of an aneurysmal bone cyst of a metatarsal: review of the differential diagnosis and treatment options.

UNLABELLED: Aneurysmal bone cyst localized to the metatarsus, while not unheard of, is rather uncommon. The differential diagnosis for this lesion can be challenging, particularly in regard to the possibility of the presence of other giant cells containing tumors of bone, such as giant cell tumor, giant cell reparative granuloma, Brown's tumor of hyperparathyroidism, and telangiectatic osteosarcoma. We report a case of an aneurysmal bone cyst localized to the third metatarsal in a 14-year-old girl who presented with limping, progressively worsening local pain, and swelling in her left foot. The differential diagnosis for her condition was extensive. Ultimately, an en bloc resection was undertaken and the defect was replaced with tricortical iliac autograft. Pathological analysis of the resected tissue was consistent with aneurysmal bone cyst. There was complete healing with no sign of recurrence 3 years after the surgery. LEVEL OF CLINICAL EVIDENCE: 4.

Skin dimpling as a complication of hamstring harvesting following anterior cruciate ligament reconstruction.

Surgical intervention to repair a torn anterior cruciate ligament (ACL) with autogenous hamstring tendons has become popular. However, hamstring graft harvesting complications can occur. This article presents a case of skin dimpling over the pes anserinus during active hamstring contraction in a 32-year-old man following arthroscopic ACL reconstruction.

The fascial band from semitendinosus to gastrocnemius: the critical point of hamstring harvesting: an anatomical study of 23 cadavers.

BACKGROUND: Arthroscopically-assisted reconstruction of the anterior cruciate ligament with hamstring tendons has achieved widespread acceptance; however, the anatomy of these tendons may cause technical problems at harvesting. METHODS: We studied the anatomy of the fascial band between semitendinosus and gastrocnemius and the distance between the semitendinosus insertion and the origin of this band in 23 knees from cadavers (17 male). The length of the semitendinosus tendon and the width of the fascial band were also recorded. RESULTS: Fascial attachment was detected in all cadavers except 1. The mean width of the band was 2.6 (1-4) cm. The mean distance from the insertion of the semitendinosus to the fascial band was 7 (6-8) cm. The mean length of the semitendinosus tendon was 22 (18-26) cm. INTERPRETATION: A better understanding of the anatomy of the hamstring tendons will reduce the risk of a disappointing complication right at the start of the operation.

Wrist tourniquet: the most patient-friendly way of bloodless hand surgery.

BACKGROUND: The literature is scarce on wrist tourniquets. In this study, three well-established locations of tourniquet setting including upper arm, proximal forearm, and wrist were compared on the same limb using both clinical as well as biochemical variables in paramedical volunteers. METHODS: Twenty unmedicated, healthy, paramedical, right-hand dominant volunteers participated in the study. The left upper arms were used for monitoring. Blood pressures and heart rates were monitored and recorded before (baseline) and immediately after the application of the tourniquet, every 5 minutes, and at the time the patient requested deflation. An intravenous cannula (22 G) was placed on the right hand to obtain samples, which were taken at baseline and immediately after deflation of the tourniquet to evaluate the levels of pO2, pCO2, O2 saturation, pH, bicarbonate, blood sugar, lactate, hematocrit, and electrolytes. The tourniquets were applied to the right upper arm, forearm, and wrist of each subject with 5-day intervals between each trial. Subjective discomfort and tourniquet pain levels were recorded. For each trial, tourniquet tolerance and details of discomfort were recorded. Statistical analysis was performed as appropriate. RESULTS: Twenty volunteers aged 20 to 44 years were included. For each trial, in the first 10 minutes after inflation of the tourniquet, the heart rate and systolic blood pressure were increased compared with baseline values. Diastolic blood pressure was elevated immediately after inflation and remained so until deflation in each trial. Diastolic blood pressure values were higher in the upper-arm tourniquet group compared with wrist. Then pH, pO2, and O2 saturation values were decreased and pCO2 and lactate levels were increased compared with baseline values in each trial. Blood sugar was decreased significantly in the arm group. The decrease in pH, pO2, O2 saturation, and blood sugar in the upper arm group was significantly higher compared with wrist and forearm groups. The lactate value was higher in the upper arm group compared with wrist. Visual analog scale and numerical rating scores were lower in the wrist group compared with others at all times. The longest tourniquet tolerance was in the wrist group. In the wrist group, curling was observed in all subjects but the fingers could easily be extended. CONCLUSION: The wrist tourniquet is the most comfortable technique of bloodless surgery for procedures limited to the hand region.

The pain associated with intraarticular hyaluronic acid injections for trapeziometacarpal osteoarthritis.

Trapeziometacarpal osteoarthritis predominantly affects middle-aged women. Most cases with rhizarthrosis can be managed successfully by conservative means. The purpose of this prospective study was to evaluate pain and tolerability of viscosupplementation therapy with hyaluronic acid (HA) for trapeziometacarpal osteoarthritis. Groups A and B consisted of eight patients each with Eaton stage 3 or 4 rhizarthrosis, who underwent one cycle of three injections of (one per week) 0.3 cm3 sodium hyaluronate. The injections for group A were under fluoroscopy control, but fluoroscopy was not used in group B. Pain and tolerability of both groups A and B were measured and compared. The patients of the groups were also asked to evaluate the tolerability of the treatment. The results suggested that HA injection in the carpometacarpal joint is a tolerable procedure but the patients complained of pain and discomfort during the injections. The pain in group A was much greater than in group B. Viscosupplementation for the treatment of trapeziometacarpal osteoarthritis is a viable treatment option for stages 3 and 4 patients when they do not want to be operated on. It is a tolerable but not a painless procedure especially when it is done without fluoroscopy control. We recommend giving injections under fluoroscopy control.