Pins and rubber band traction for treatment of comminuted intra-articular fractures in the hand.

PURPOSE: To determine the efficacy of pins and rubber band traction for treatment of comminuted intra-articular fractures in the hand. METHODS: We performed a retrospective study from 1994 to 2013 to evaluate 33 patients in whom pins and rubber band traction was employed. We clinically evaluated the active range of motion of the affected fingers after surgery. Eleven of the 33 fractures were at the proximal interphalangeal joint, 10 at the distal interphalangeal joint, 5 at the thumb interphalangeal joint, and 2 at the metacarpophalangeal joint of the thumb. The remaining 5 patients had complex fracture-dislocation of the proximal interphalangeal joints. RESULTS: The mean follow-up period was 24 months. The average active motion of the metacarpophalangeal joints of the fingers was 91° (range, extension 0°-10°/flexion 85°-90°), proximal interphalangeal joints was 92° (range, extension/flexion 0°-10°/85°-100°), and distal interphalangeal joints was 73° (range, extension/flexion 0°-10°/60°-80°). The overall average of all active motion of the injured fingers except thumbs was 255° (range, 240°-270°). The average active motion of the of the thumb metacarpophalangeal joint was 56° (range, extension 5°-10°/flexion 50°-55°), and interphalangeal joint was 74° (range, extension 0°-10°/flexion 75°-80°). The average of active motion of the injured thumb metacarpal and interphalangeal joints combined was 130° (range, 125°-135°). CONCLUSIONS: Pins and rubber band traction is a treatment option for comminuted displaced intra-articular fractures of the digits that offers satisfactory clinical results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Can radiation exposure to the surgeon be reduced with freehand pedicle screw fixation technique in pediatric spinal deformity correction? A prospective multicenter study.

STUDY DESIGN: Prospective multicenter study of patients who underwent pediatric spinal deformity correction with posterior spinal fusion and instrumentation. OBJECTIVE: To quantify radiation exposure to the surgeon during pedicle screw fixation using the freehand technique in pediatric spinal deformity surgery. SUMMARY OF BACKGROUND DATA: Pedicle screw placement in thoracic and lumbar spine for spinal deformity is technically demanding and involves radiation exposure. Many experienced spinals surgeons use the freehand technique for pedicle screw fixation in spinal deformity surgery. There are no studies analyzing radiation exposure to the surgeon regarding freehand pedicle screw fixation technique. METHODS: A prospective multicenter study was designed to evaluate radiation exposure to the operating spinal surgeon who uses the freehand pedicle screw fixation technique in pediatric spinal deformity correction. All of the operating surgeons placed a gamma radiation dosimeter on their chest outside the lead apron during surgery. Surgeons placed pedicle screws in the pediatric spinal deformity using the freehand technique. We included patients who had undergone correction with posterior spinal fusion and instrumentation with all pedicle screw constructs in this study. RESULTS: We analyzed 125 patients with pediatric spinal deformity who were operated on between 2008 and 2012. The average fluoroscopic time was 40.5 ± 21 seconds. The overall average fluoroscopic time for placement of a single pedicle screw and per fixation level were 2.6 ± 1.7 seconds and 3.9 ± 2.5 seconds, respectively. In each surgery, the recorded radiation exposure to the surgeon was less than the minimum reportable dose (<0.010 mSv) with an average of 0.0005 ± 0.00013 mSv per surgery. CONCLUSION: The use of freehand technique for pedicle screw fixation in spinal deformity correction requires a minimum amount of fluoroscopic use, hence decreasing radiation exposure to the surgeon and patient. LEVEL OF EVIDENCE: 4.

Prospective study of percutaneous radiofrequency nerve ablation for chronic plantar fasciitis.

BACKGROUND: Chronic plantar heel pain is one of the most painful foot conditions and is generally associated with plantar fasciitis. This study reports 2-year follow-up results of radiofrequency nerve ablation (RFNA) of the calcaneal branches of the inferior calcaneal nerve in patients with chronic heel pain associated with plantar fasciitis. METHODS: After receiving approval from the institutional review board, we prospectively evaluated the results of the RFNA of the calcaneal branches of the inferior calcaneal nerve on 35 feet in 29 patients with plantar heel pain between 2008 and 2011. All of the patients who were treated had been complaining of heel pain for more than 6 months and had failed conservative treatment. All of the patients were evaluated (quantitatively) using the average 10-point Visual Analog Scale (VAS) before treatment, as well as at their 1-month, 1-year, and 2-year follow-up after the procedure. We also evaluated 26 feet in 20 patients with American Orthopaedic Foot and Ankle Society scale (AOFAS) scores before the treatment, as well as at their 1-month, 1-year, and 2-year follow-up after the procedure. RESULTS: The average VAS score of the feet was 9.2 ± 1.9 before treatment, 0.5 ± 1.3 at 1 month after the procedure, 1.5 ± 2.1 at 1-year follow-up, and 1.3 ± 1.8 at 2-year follow-up (P < .001). The average AOFAS scores of the patients were 66.9 ± 8.1 (range, 44-80) before treatment, 95.2 ± 6.1 (range, 77-100) at 1 month after the procedure, 93 ± 7.5 (range, 71-100) at the 1-year follow-up, and 93.3 ± 7.9 (range, 69-100) at the 2-year follow-up. At the 1- and 2-year follow-up, 85.7% of the patients rated their treatment as very successful or successful. CONCLUSION: These findings suggest that RFNA of the calcaneal branches of the inferior calcaneal nerve was an effective pain treatment option for chronic heel pain associated with plantar fasciitis that did not respond to other conservative treatment options. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Artery-only fingertip replantations using a controlled nailbed bleeding protocol.

PURPOSE: We report our experience, treatment protocol, and 2-year follow-up results of 24 fingertip replantations treated using the artery-only technique without vein or nerve repair. METHODS: We performed a retrospective review of 24 patients who had undergone fingertip replantation at the same center between 2005 and 2011. All patients in this study had complete fingertip amputation at or distal to the distal interphalangeal joint of the fingers or interphalangeal joint of the thumb. Patients with incomplete and complete amputations who had undergone vein and/or nerve repair along with artery repair were excluded. All patients received the same protocol including removal of the nail at the surgery and intravenous heparin 70 U/kg administered at the time of arterial anastomosis. After surgery, the nailbed was mechanically made to bleed with a sterile needle and mechanically scrubbed with a heparin-saline gauze. All patients received the same postoperative medical treatment protocol until physiological outflow was restored. Successful replantation was confirmed with clinical observation. RESULTS: Twenty-one of the 24 fingertip replantations (88%) were successful. The mean length of hospital stay was 7 days (range, 4-9 d). Fifteen of 22 patients required blood transfusion. The average amount of blood transfusion was 1.2 U (range, 0-3 U). CONCLUSIONS: This study shows that the described technique and protocol reconstructed circulation without vein anastomosis and with a high success rate. Furthermore, adequate sensory recovery without any nerve repair had occurred by the 2-year follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Treatment of chronic lateral instability of the ankle with the Colville technique: a prospective analysis with minimum five years of follow-up.

OBJECTIVES: This study aims to prospectively analyze of the long-term results of the Colville's technique for the treatment of chronic lateral ankle instabilities. PATIENTS AND METHODS: Twenty-eight ankles of 28 male patients (mean age 24.6 years; range 20 to 35 years) which were treated using Colville's technique were evaluated with a mean follow-up of 76.1 months (range 60 to 106 months). Ankle instability, ankle functions and outcomes in the last visit were assessed and statistically compared. Stress radiographs with the TELOS device were repeated at six-months and five-years after surgery and compared with the stability of the uninjured ankle. RESULTS: Twenty-three of the results were excellent and five were good according to the criteria of Chrisman and Snook. All patients returned to normal daily activity levels at an average of eight months following surgery. Radiographic analysis revealed the significant preservation of stability at least five years after surgery with no sign of arthritis. The difference between preoperative and sixth-months postoperative values of both the talar tilt and the anterior draw tests were found statistically significant, indicating significant correction of the laxity. On contrary, difference between sixth months and five year values were not statistically significant, indicating the preservation of the correction. CONCLUSION: Anatomical augmented reconstruction procedure of Colville's is a long-lasting and good alternative compared to other more complex techniques of reconstruction with minimum long-term complications.

Correction of syndactyly using a dorsal separated V-Y advancement flap and a volar triangular flap in adults.

Skin grafts and local flaps are conventional methods of repair for congenital syndactyly, but the results obtained are not always as functional and aesthetic as desired and frequently leave postoperative scars and residual syndactyly. In this article, we describe a new surgical technique for web reconstruction in the correction of simple, incomplete syndactyly. The technique consists of a dorsal separated V-Y advancement flap and a volar triangular flap to cover the newly created web space, thus avoiding skin graft in this space. In all, 15 web spaces in 10 patients were treated using this method. A follow-up period of 6 months to 2 years showed neither recurrence of the deformity nor web creep of any degree. The technique is rapid, safe, easily performed, and reproducible and requires a single surgical procedure. It uses donor tissue identical in color, texture, and thickness, which renders acceptable cosmesis in cases of simple, incomplete syndactyly, therefore, avoiding the use of skin grafts and resulting postoperative scar contracture in the web space.

Treatment of a unicameral bone cyst of calcaneus with endoscopic curettage and percutaneous filling with corticocancellous allograft.

The surgical procedures for unicameral solitary calcaneal bone cysts have ranged from simple curettage and grafting to subperiosteal resection with internal fixation and grafting. In this article, an endoscopically assisted technique is proposed for the curettage of a simple calcaneal cyst that takes advantage of direct visualization of the cyst wall and contents and permits accurate assessment of the extent of the lesion. After curettage, percutaneous filling of the defect with corticocancellous allograft makes the technique a complete, minimally invasive surgical approach for this condition. The technique uses 2 lateral portals, one for viewing and the other for manipulation, both of which are created under fluoroscopic control. Once the cyst has been located, the 30 degrees arthroscope is used to evacuate fluid, after which more solid cyst contents are fragmented and removed. Thereafter, curettage of the inner surface of the cavernous cyst wall is performed. Finally, complete packing of the previously cystic cavity with crushed corticocancellous allograft is performed under endoscopic visualization and confirmed radiographically.

Mass casualties from acute inhalation of chlorine gas.

OBJECTIVES: Chlorine gas is a potent pulmonary irritant that affects the mucous membranes and induces severe disturbances of pulmonary gas exchange within minutes of inhalation. The present study evaluated an extraordinary type of mass inhalational exposure. MATERIAL AND METHODS: Clinical reports of 25 soldiers who were admitted to the emergency department of Maresal Cakmak Military Hospital, Erzurum were retrospectively evaluated. All patients were exposed to chlorine gas as a result of mixing sodium hypochlorite with hydrochloric acid during cleaning activities. RESULTS: All patients were male and the mean age of patients was 22.04+/-2.98 years. The main symptoms were coughing and dyspnea in 18 patients (72%). Forced expiratory volume in 1 second (FEV1) and FEV1/forced volume capacity (FVC) ratio were found to be normal in all patients but FVC and peak expiratory flow (PEF) were below the normal range (80%) in 9 patients (36%). All patients received warmed humidified oxygen combined with nebulized salbutamol. Inhaled budesonide and nebulized sodium bicarbonate were ordered additionally for 19 patients (76%). Thirteen patients (52%) were discharged from the emergency department and 12 patients (48%) were hospitalized. No mortality was observed. CONCLUSION: Chlorine gas is a potent pulmonary irritant that causes acute damage in both the upper and lower respiratory tract. We suggest that inhaled steroids combined with nebulized sodium bicarbonate could be a safe and effective alternative for the treatment of symptomatic patients. Education of the public about the dangers of mixing of hypochlorite bleach with acidic cleaning agents is also very important.

Acute arthroscopic removal of a bullet from the shoulder.

Arthroscopic procedures are frequently used for extraction of foreign bodies such as bullets from joints. Retained bullets have some effects as loose bodies that cause mechanical symptoms and destroy articular cartilage. Bullets and lead particles in synovial fluid dissolve in time and cause periarticular fibrosis, chondrolysis, hypertrophic arthropathy, and sometimes chronic lead intoxication. A 21-year-old man was treated after he sustained a gunshot wound to his left shoulder. Shoulder arthroscopy was performed through the standard posterior portal. The bullet was observed in the posterior recess and was removed by means of a 10-mm cannula placed anteriorly. The use of arthroscopy for removal of the bullet from the shoulder joint of this patient minimized surgical dissection and blood loss and reduced the likelihood of complications. The patient was free of symptoms within 1 month. Given the disadvantages of traditional techniques such as heavy blood loss, large incisions, high risk for neurovascular anatomic structures, poor visualization of articular surfaces, and prolonged recovery times, we recommend arthroscopic removal of foreign bodies from the shoulder joint as an excellent choice for the treatment of patients with such intra-articular injuries.

Comparison of outcomes of two different surgeries in regarding to complications for chronic anterior shoulder instability.

INTRODUCTION: The purpose of this study is to compare the early clinical results of two techniques in regarding to complications in the patients who suffered from chronic anterior traumatic isolated shoulder instability. METHOD: Eighty-five patients underwent reconstructive procedures due to chronic isolated traumatic shoulder instability in our clinic between 1990 and 2002. Sixty-four patients in whom preoperatively Bankart lesion were detected with MRI and who participated in the regular follow-up were included in the study. Thirty-four patients were treated with Bankart repair (Group I) and 30 patients were treated with Modified Bristow procedure (Group II). Mean follow-up period was 25 (24-39) months for group I and 28 (24-96) months for group II. All cases were evaluated preoperatively and postoperatively according to Rowe scoring system. RESULTS: Mean Rowe scores were 90 and 88.1 for group I and II, respectively. Due to recurrent dislocation, four revision surgeries (one in group I, three in group II) were performed. Surgical complications were encountered in group II, just as fracture at the bone block in four cases, nonunion in five cases and removal of loose screw in one case. DISCUSSION: According to clinical outcomes, both the techniques are useful and feasible for the treatment of the chronic traumatic isolated anterior shoulder instability; however, complication rate is higher in the Modified Bristow technique and, Bankart repair is directed to the anatomic repair of the original pathology.

Treatment of rupture of the Achilles tendon with fibrin sealant.

BACKGROUND: The optimal management strategy for acute Achilles tendon ruptures is controversial. These injuries historically were treated by nonoperative methods (cast immobilization, bandaging); however, operative repair of the ruptured tendon has become popular. METHODS: Thirty-two patients who had rupture of the Achilles tendon were treated operatively with use of fibrin sealant, and clinical and functional performance measures were assessed after a mean followup of at least 6 months between November, 1998, and July, 2003. All of the patients were male. Average age was 38.18 (30 to 45) years. All of the patients were followed for at least 18 months after surgery. Average followup time was 22.4 (18 to 56) months. We evaluated all patients according to the scoring system of Thermann et al. RESULTS: Our results were excellent in 24 patients and good in eight patients. One patient had rerupture 3 weeks after surgery. CONCLUSION: Fibrin sealants are biologically compatible, hemostatic agents derived from human plasma that can be used instead of suture or suture support. We think that the treatment of rupture of the Achilles tendon with fibrin sealant is a useful treatment, and there is less risk of complications, such as deep infection, than in other operative procedures. We had no wound closure problems, the incision size was small, and the operating time was short. However, it must be remembered that the risk of disease transfer by fibrin sealant application is still present.

[Early results of reconstruction of chronic anterior cruciate ligament ruptures using four-strand hamstring tendon autografts]. / Kronik ön çapraz bag yirtiginin dörtlü hamstring otogrefti ile rekonstrüksiyonunun erken dönem sonuçlari.

OBJECTIVES: We evaluated the short-term results of reconstruction of anterior cruciate ligament (ACL) ruptures using a four-strand hamstring autograft and cross pin femoral fixation. METHODS: The study included 62 male patients (mean age 24 years; range 21 to 44 years) with chronic ACL ruptures. Involvement was in the right knee in 32 patients, and in the left knee in 30 patients. All the patients were treated with a four-strand hamstring autograft, cross pin femoral fixation (Transfix, Arthrex and Sling Shot, Mitek), and an interference screw on the tibial side. Forty-one patients received treatment for other meniscal pathologies. Final evaluations were made at the end of postoperative 18 months using the Lysholm and IKDC (International Knee Documentation Committee) scoring systems, Telos stress testing, Tegner activity rating, and radiographs. RESULTS: The Lysholm scores were good (n=23) or excellent (n=38) in 61 patients, and poor in one patient, the mean Lysholm score being 93.5. The IKDC scores were grade A (n=35) or B (n=26) in 61 patients, and grade D in one patient. Telos stress testing showed a significant difference between preoperative (mean 14.5 mm) and postoperative (mean 2.6 mm) laxity measurements (p<0.001). None of the patients had a graft rupture. One patient who developed grade III instability after postoperative six months underwent second-look arthroscopy followed by revision surgery. CONCLUSION: Reconstruction of the ACL using four-strand hamstring tendons and cross pin femoral fixation results in considerably high success rates in selected patients.

Late reconstruction of neglected metacarpal shaft defects due to gunshot wound.

We evaluated eight patients after delayed treatment of nine metacarpal bone defects due to gunshot injuries. The mean length of the metacarpal defects was 3 cm and the average time between the gunshot injury and the reconstruction surgery was 10 months. Although all of the patients had been treated with wound irrigation and debridement immediately following injury, no attempt had been made to repair the metacarpal defect or to maintain metacarpal length. As a result, serious shortening had occurred. After the original length of the metacarpal had been restored by distraction of the soft tissues (1 mm/day), a tri-cortical iliac bone graft was inserted into the bone defect. The average follow-up time was 15 months. Clinical and radiological union was established in all cases after an average of 12 weeks. The mean grip strength of the hand and the mean range of motion of the metacarpophalangeal joint increased by 24% and 60%, respectively.

Biodegradable implants in the treatment of scaphoid nonunions.

We reviewed 12 male patients with scaphoid nonunions treated by open reduction, bone grafting, and internal fixation with biodegradable implants made of self-reinforced poly- l-lactic acid. Mean patient age was 22.5 (20-25) years. Ten patients had type D2 scaphoid nonunions with a fracture line in the middle one third, one patient had type D2 nonunion with a fracture line in the proximal one third, and one patient had type D1 distal one-third fibrous union. The mean wrist score (modified Mayo wrist score) was 20.8 (10-40) preoperatively and improved after 22-80 months (55-90). All nonunions healed, and the mean solid union time was 4.5 (3.5-7) months. We obtained excellent results in five patients, good results in four, fair results in two, and a poor result in one. The results of this study offer a valid alternative in the fixation of scaphoid nonunions. The major advantage of biodegradable materials is to eliminate the requirement for the removal of the fixation material.

Proximal oblique crescentic osteotomy in hallux valgus.

Twenty-six patients with moderate-to-severe hallux valgus deformities were evaluated before and after treatment. All of the patients had incongruent great toe joints. The patients underwent modified proximal crescentic osteotomy, which was termed proximal oblique crescentic osteotomy. The results were evaluated at an average follow-up time of 55 weeks. Objective criteria were hallux valgus angle, intermetatarsal angle, shortening of the first metatarsal, and angulation at the osteotomy site. Clinical evaluation was made according to the rating system of the American Orthopaedic Foot and Ankle Society. The mean correction of the hallux valgus and intermetatarsal angles was 22.1 degrees and 9.9 degrees, respectively. Short-term results indicate that proximal oblique crescentic osteotomy is effective in the treatment of hallux valgus; its advantages over other procedures include its technical ease and low rate of complications.

[Delayed diagnosis of isolated ulnopalmar dislocation of the fifth carpometacarpal joint and its treatment with open reduction and internal fixation]. / Besinci karpometakarpal eklemde tanisi geç konan izole ulnopalmar çikigin açik redüksiyon ve internal fiksasyonla tedavisi.

We present a 21-year-old male patient with an isolated ulnopalmar dislocation of the fifth carpometacarpal joint that occurred due to a fall on the hand. Diagnosis was delayed for five weeks and closed reduction was not successful. He was treated with open reduction and internal fixation. Upon removal of fixation materials six weeks after surgery, he developed reflex symphatic dystrophy and limitation in joint movements, which disappeared following rehabilitation and medical treatment at the end of 15 weeks. Functional and radiographic results were satisfactory.