Dorsal nail plate versus percutaneous k-wire fixation in the treatment of displaced distal radius fractures.

Distal radius fractures are the most common fractures in the elderly, yet the treatment is controversial and still debated in the literature. Twenty four patients aged older than sixty with distal radial fractures were treated by dorsal nail plate. We compared them with twenty four similar matched patients treated by percutaneous Kirschner wiring surgical method. The patients were operated on by a surgeon experienced in carrying out hand surgery. The purpose of this retrospective review was to compare the clinical and radiological outcomes in elderly patients with displaced distal radial fractures who were treated with either the dorsal nail plate or percutaneous Kirschner wiring surgical procedures. Both groups had high union rates and low complication rates for the treatment of displaced distal radius fractures in elderly patients. However, better functional results can be expected in dorsal nail plate.

Advantages of using volar vein repair in finger replantations.

Providing adequate venous outflow is essential in finger replantation surgeries. For a successful result, the quality and quantity of venous repairs should be adequate to drain arterial inflow. The digital dorsal venous plexus is a reliable source of material for venous repairs. Classically, volar digital veins have been used only when no other alternative was available. However, repairing volar veins to augment venous outflow has a number of technical advantages and gives a greater chance of survival. Increasing the repaired vein:artery ratio also increases the success of replantation. The volar skin, covering the volar vein, is less likely to be avulsed during injury and is also less likely to turn necrotic, than dorsal skin, after the replantation surgery. Primary repair of dorsal veins can be difficult due to tightness ensuing from arthrodesis of the underlying joint in flexion. In multiple finger replantations, repairing the volar veins after arterial repair and continuing to do so for each finger in the same way without changing the position of the hand and surgeon save time. In amputations with tissue loss, the size discrepancy is less for volar veins than for dorsal veins. We present the results of 366 finger replantations after volar vein repairs.

An alternative classification of occupational hand injuries based on etiologic mechanisms: the ECOHI classification.

BACKGROUND: The aim of this study was to construct an alternative classification system for occupational hand injuries based on etiologic mechanisms and to analyze the injury patterns resulting from various mechanisms. METHODS: A retrospective analysis of patients operated between January 2005 and December 2007 in two hand surgery units staffed by a team of hand surgeons was made. The patient files were retrospectively examined, and mechanisms causing the injuries were analyzed. Similar mechanisms were classified in the same groups, and the mechanism of injury was matched with type of injury often caused by this mechanism. In the classification of injuries, the tissues that were injured were taken as a basis for classification. 4120 upper extremity injuries were seen in the study hospitals, and 2188 (53.1%) of them were occupational injuries. There were 2063 males (94.3%) and 125 females (6.7%). The mean age was 28.2 (range: 15-71) years. RESULTS: Examination of the agents causing injury yielded 62 agents. Further examination of these agents showed that the mechanism by which they caused injury was similar in some agents, and these agents were placed in the same groups, which constituted the Etiologic Classification of Hand Injuries (ECOHI) classification. These groups of mechanisms were: cutting-penetrating, cutting-crushing, crushing-penetrating, crushing-compressing, crushing-burning, stinging, avulsing, electrical current, and chemical injuries and miscellaneous burns. The two most common mechanisms were crushing-compressing and cutting-crushing types, constituting 744 (34.0%) and 514 (23.5%) of injuries, respectively. CONCLUSION: We believe that ECOHI is important to form a common language for the classification of etiologic factors.

Reconstruction of complex groin defects with inferior epigastric artery-based rectus abdominis muscle flaps: report of two cases.

Because the extremities are dependent on a single vascular supply, namely the brachial and femoral arteries, injuries around the girdles are challenging, and may contribute to high morbidity rates such as extremity loss, or even mortality due to bleeding, sepsis or vascular compromise. The reconstruction or aided closure of these regions may present additional technical difficulties in the presence of a vascular injury that complicates the use of a microvascular-free transfer, which sometimes may be needed to cover the exposed vessels, bones, tendons, and cartilages whenever the neighboring skin and subcutaneous tissue are inadequate or demised. In these circumstances, pedicled regional flaps of muscular or musculocutaneous consistency (especially if a bulk or rich vascular tissue is needed) would be an alternative. In this report, we present two cases that underwent femoral artery repair via saphenous vein grafting in the vascular surgery clinic followed by our inferiorly based pedicled rectus abdominis muscle flap coverage procedure.

Ligament reconstruction using the Fulkerson-Watson method to treat chronic isolated distal radioulnar joint instability: short-term results.

OBJECTIVE: Isolated distal radioulnar instability may remain unrecognized during the acute period of trauma as it is difficult to diagnose, and does not become obvious until later when it has become chronic. We present early results in patients who underwent stabilization with extraarticular ligament reconstruction (Fulkerson-Watson reconstruction). METHODS: Four women and 1 man underwent surgery for chronic isolated distal radioulnar joint instability demonstrated in X-rays and magnetic resonance images. Arthroscopy revealed avulsion of the triangular fibrocartilage complex from the point of insertion in 3 patients, and peripheral tears in 2 patients. The peripheral tears were debrided arthroscopically. All patients had an adequate sigmoid notch and therefore underwent ligament reconstruction using the Fulkerson-Watson method. Postoperative evaluations were done with MRI. RESULTS: Mean follow-up was 15.5 months (range 6-26 months). Stability was achieved in all patients. The mean Quick-DASH symptom score decreased from 18.63 (15.90-22.72) to 6.81 (2.27-9.09) after surgery. A mean visual analogue score to assess pain decreased from 7.32 (6.30-8.40) to 1.88 (1.50-2.30) after surgery. Preoperative and postoperative measurements were 26° (passive 44°) and 47° (passive 65°) for active supination, 18° (passive 45°) and 49°(passive 68°) for active pronation, 20° (passive 43°) and 42° (passive 60°) for active wrist flexion,and 38° (passive 52°) and 45° (passive 59°) for active wrist extension. CONCLUSION: Surgical revision of distal radioulnar joint instability using Fulkerson-Watson reconstruction is easier than intraarticular techniques and satisfactorily re-establishes stability, provided that the sigmoid notch is adequate.

Muscle transposition and circumferential vacuum-assisted closure to salvage the knee joint in transtibial amputation of the leg: case report.

Degloving injury is the avulsion of the skin off the underlying muscle and bone, which may also involve the latter structures in high-energy trauma. This study reports the case of a 33-year-old male patient who sustained a motorcycle accident and presented with hypovolemic shock, multiple fractures, and multiplanar degloving injury of the leg. The foot and distal leg was not salvageable, and a transtibial amputation with anterior transposition of the posterior compartment muscles was performed; however, a circumferential skin necrosis involving the stump and the knee joint occurred. The wound granulated rapidly using circumferential vacuum-assisted closure therapy and subsequently repaired with split thickness skin grafts. The authors found the topical negative pressure using the Vacuum Assisted Closure (VAC) technique Trademark KCI, Texas, USA, method to be helpful in the care of lower extremity degloving injury, enabling less frequent dressing changes and facilitating formation of granulation tissue with rapid preparation of the wound bed for salvage of the knee joint.

Fractures of the fingers missed or misdiagnosed on poorly positioned or poorly taken radiographs: a retrospective study.

BACKGROUND: Missed fractures, the most common diagnostic error in emergency departments, are usually the result of a misread radiograph or the failure to obtain a radiograph. However, a poorly positioned or poorly taken radiograph may also result in diagnostic errors. We sought to analyze the frequency of missed or misdiagnosed finger fractures that could be attributed to inadequate radiographs. METHODS: We reviewed the medical records of the hand surgery divisions of Istanbul Bilim University Medical Faculty Hospital and the Orthopedics Department of Private Florence Nightingale Hospital between January 2008 and March 2010 for patients with fractures of the fingers that had been missed or misdiagnosed on the basis of inadequate radiographs. RESULTS: In 182 patients, we identified 7 missed and 7 misdiagnosed fractures of the fingers because of inadequate radiographs. Lack of a true lateral radiographic view of the fingers or a true anteroposterior radiographic view of the thumb was the most frequent reason for diagnostic errors (71%; 10 of 14), leading to missed fractures in six patients and to misdiagnosed fractures in four patients. Superimposition of the fingers on lateral radiographs led to misjudging of displaced proximal phalangeal fractures of the fifth finger in three patients. CONCLUSION: Diagnostic errors attributed to inadequate radiographs are rare. Proper radiographic evaluation of finger trauma requires at least true anteroposterior and lateral views. An oblique view can complement the lateral view but not replace it. Poor quality radiographs or inadequate views should never be accepted or used as a basis for treatment.

Evaluation of patients undergoing removal of glass fragments from injured hands: a retrospective study.

The hand is the body part most frequently injured by broken glass. Glass fragments lodged in soft tissues may result in numerous complications, such as infection, delayed healing, persistent pain, and late injury as a result of migration. Between 2005 and 2010, we removed 46 glass particles from the hands of 26 patients. The injuries were caused by the following: car windows broken during motor vehicle accidents in 11 patients (42%); fragments from broken glasses, dishes, or bottles in 9 (35%); the hand passing through glass in 5 (19%); and a fragment from a broken fluorescent lamp in 1 (4%) patient. Despite the efficacy of plain radiographs in detecting glass fragments, these are sometimes not obtained. Given the relatively low cost, accessibility, and efficacy of radiographs, and the adverse consequences of retained foreign bodies, the objections to obtaining radiographs should be few in diagnosing glass-related injuries of the hand.

Delayed rupture of the extensor hallucis longus and extensor digitorum communis tendons after breaching the anterior capsule with a radiofrequency probe during ankle arthroscopy: a case report.

A 40-year-old man with early arthritis, loose bodies, and anterolateral joint impingement symptoms in his left ankle, which was refractory to noninvasive therapeutic modalities for 1 year, underwent ankle arthroscopy and radiofrequency thermal ablation. The anterior capsule of the ankle joint was breached by the radiofrequency probe while the loose bodies were removed from the anterior recess, exposing the extensor tendons and resulting in a delayed spontaneous rupture of the extensor hallucis longus tendon and extensor tendons to the second and third toes. The extensor hallucis longus tendon was repaired with a semitendinosus tendon graft, and extensor digitorum tendons underwent primary repair. The patient regained full function and was symptom free 1 year after surgery.

Protective effect of grape seed extract against ischaemia/reperfusion injury in a rat epigastricflap model.

Proanthocyanidins are potent natural antioxidants which belong to a class of polyphenols. Proanthocyanidin-rich extracts are prepared from grape seeds. The effect of grape seed proanthocyanidin extract (GSPE) on the viability of abdominal skin flaps exposed to warm ischaemia and subsequent reperfusion were studied in 40 male Wistar rats. In the control group (group I; n=20), rats were fed with standard, non-purified rat diet, and the study group received GSPE 100 mgkg(-1) per day 1 week prior to surgery and 1 week following surgery. Abdominal island flaps were elevated in both the groups and subjected to 8h of warm ischaemia, followed by reperfusion. Mean flap survival areas in groups I (control group) and II (treatment group) were calculated to be 58.3%+/-11.72 and 81.0%+/-11.88, respectively. Flap survival on day 7 was significantly higher in group II compared to group I (p<0.01). Histopathological semi-quantitative analysis of the specimens revealed infiltration by polymorphonuclear leucocytes, oedema formation and necrosis in group I, whereas neo-vascularisation and fibrosis were the prominent findings in group II.

[Tendon transfers for the upper extremity in cerebral palsy]. / Spastik üst ekstremitede cerrahi tedavi: Tendon transferi uygulamalari.

Upper extremity deformities in cerebral palsy are caused by the imbalance between spastic and weak muscles acting on unstable joints. The basic goals of surgical treatment of spastic hands and upper extremities of patients with cerebral palsy can be summarized as reducing the strength of spastic muscles, strengthening the antagonist muscles, and permanent stabilization of unstable joints. Surgical techniques to achieve these goals include lengthening of spastic muscles, tendon transfers, release or plication of the joint capsule, joint arthrodesis, neurectomies, and skin procedures. Amongst these surgical treatment options, this article will present, in more detail, tendon transfers which are performed especially to achieve balance and restore motor functions.

[Evaluation of long-term results in mutilating hand injuries]. / Agir hasarli el yaralanmalarinda tedavi sonuçlarinin degerlendirmesi.

BACKGROUND: The aim of this study is to report the surgical procedures performed in patients with mutilating hand injuries and evaluate the outcomes of treatment. METHODS: A retrospective evaluation of 130 patients operated between 2000 and 2005 for mutilating hand injuries is presented. Twenty-five of the patients could be followed until the end of rehabilitation. The grip power and ranges of motion in affected joints were determined. Minnesota manipulation speed test and Purdue Pegboard Test were used for evaluation of functional results. RESULTS: Mean range of motion was 64.7% (minimum: 17%, maximum 96%) of the uninjured extremity. Mean grip strength was 52% (15-80%) of the uninjured extremity. Lateral pinch was 66% (25%-81%) of the contralateral hand and the results were 53% (12%-68%) for key pinch and 52% for tripod pinch. Minnesota manipulation speed test showed satisfactory results in 92% of the patients in hand skill, strength and coordination. A decrease in fine motor skills was observed in Purdue Pegboard Test. CONCLUSION: The main treatment purposes in mutilating hand injuries are obtaining an extremity that is useful in daily activities and if possible that facilitates a return to work.

Tibialis posterior tendon transfer for persistent drop foot after peroneal nerve repair.

Despite advances in the surgical treatment of peroneal nerve injuries, a significant fraction of patients do not recover adequately. Among 35 patients who had previous repair of the peroneal nerve, 19 had permanent drop foot, and 16 of these patients underwent tibialis posterior (TP) tendon transfer. Mean duration of paralysis was 26.7 (range, 7 to 192) months. TP tendon was carried to the anterior compartment via the circumtibial route, and then attached to the tibialis anterior, extensor hallucis longus, extensor digitorum communis, and peroneus tertius tendons using tendon-tendon anastomosis. All patients except for one achieved active dorsiflexion to or beyond neutral. Mean preoperative drop foot angle increased from -33.8 degrees to + 9.7 degrees. According to the Stanmore system, the results were excellent in 10 patients (62.5%), good in 4 (25.0%), fair in 1 (6.2%), and poor in 1 (6.2%). The average Stanmore score was 85, which corresponded to an excellent result. We believe that the TP tendon transfer is a straightforward and reliable solution in the treatment of drop foot.

[Replantation of the ear without microvascular anastomosis: a case report]. / Mikrocerrahi uygulanmayan kulak replantasyonu: Olgu sunumu.

A 42-year-old man presented with a left-sided supralobular total ear amputation resulting from an occupational accident. Initial dissection of the amputated ear revealed no suitable vessel for anastomosis. The fenestrated cartilage with its posterior skin excised was attached as a composite graft. Four days postoperatively, it was observed that 90% of the graft was viable. Three weeks later, subtotal separation of the ear (80%) was performed combined with skin grafting for surfacing the postauricular defect. At one-year follow-up, there was partial cartilage resorption with pigmentation and minimal hyperemia of the overlying skin.

[Detection and typing of human papilloma virus by polymerase chain reaction and hybridization assay in cervical samples with cytological abnormalities]. / Sitolojik atipi izlenen servikal örneklerde insan papilloma virusunun polimeraz zincir reaksiyonu ve hibridizasyon yöntemleriyle saptanmasi ve tiplendirilmesi.

Certain mucosa-tropic human papillomavirus (HPV) types are associated with carcinoma of the uterine cervix or its precursor lesions. In addition to cytological screening, early diagnosis and treatment of cervical carcinoma rely on sensitive detection and typing of HPV isolates. In this study, HPV detection and typing were performed in the cervical samples of patients with abnormal cytological evaluation. Forty randomly-selected cervical samples that comprise 18 ASC-US (Aypical Squamous Cells of Undetermined Significance), four AG-US (Aypical Glandular cells of Undetermined Significance), one ASC-H (Atypical Squamous Cells-can not exclude HSIL), one HSIL (High-grade Intraepithelial Lesion), 14 LSIL (Low-grade Intraepithelial Lesion), one adenocarcinoma and one squamous cell carcinoma, obtained by a commercial liquid-based cytology system (ThinPrep Pap Smear Method, Cytyc, USA), were included to the study. HPV-DNA detection were accomplished by L1 in-house polymerase chain reaction (PCR) performed using MY09/11 and GP5/6 primers along with a commercial real-time PCR (HeliosisTM HPV LC PCR Kit; Metis Biotechnology, Turkey) that detects HPV infections and HPV-16 via melting curve analysis. A commercial PCR-array hybridization test (Rapid HPV Genotyping MacroArray; HybriBio Inc, Hong Kong) that can identify 21 low and high risk HPV types was employed for typing. Viral DNA was detected in 35% (14/40) and 57.5% (23/40) of the samples by MY09/11 and GP5/6 primers, respectively. All in-house PCR positive samples were also positive in the real-time PCR assay. PCR-array hybridization assay provided typing results in 95.6% (22/23) of the PCR positive samples while one LSIL sample could not be typed by any of the methods used. High risk HPV types 16, 18, 31, 45, 52, 56, 58, 59,68 (65.8%); probable high risk type 53 (13.2%), low risk types 6, 42 and 81 (21%) were identified out of a total of 38 HPV isolates. Multiple infections with more than one HPV type were identified in 45.5% (10/22) of positive samples. High/probable high risk types were detected in all single infections and all low risk isolates were present in multiple infections. HPV-16 was identified in 31.8% (7/22) by real-time PCR and in 45.5% (10/23) of positive samples by PCR-array hybridization assay. HPV-16 was observed to be the most frequently detected type (10/22, 45.5%), followed by types 53 and 81 (5/22, 22.7%); 68 (4/22, 18.2%); type 58 (3/22; 13.6%); types 31, 42 and 59 (2/22; 9.1%) and others (1/22, 4.5%). As a result our data have indicated the abundance of high risk HPV isolates and infections with multiple HPV types in that specific area.

Sensory outcome of fingertip replantations without nerve repair.

The sensory recovery outcomes of fingertip replantations without nerve repair were retrospectively studied. Between 2000 and 2006, 112 fingertip replantations with only arterial repair were carried out in 98 patients. About 76 of the replants survived totally, with a success rate of 67.8%. Evaluation of sensory recovery was possible in 31 patients (38 replantations). Sensory evaluation was made with Semmes-Weinstein, static and dynamic two-point discrimination, and vibration sense tests. Fingertip atrophy, nail deformities, and return to work were also evaluated. According to the Semmes-Weinstein test, 29.0% (11/38) of the fingers had normal sense, 60.5% (23/38) had diminished light touch, 7.9% (3/38) had diminished protective sensation, and 2.6% (1/38) had loss of protective sensation. Mean static and dynamic two-point discriminations were 7.2 mm (3-11 mm), and 4.60 mm (3-6 mm), respectively. Vibratory testing revealed increased vibration in 42.1% of the fingers, decreased vibration in 36.8%, and equal vibration when compared with the non-injured fingers in 21.1%. Atrophy was present in 14 (36.8%) fingers and negatively affected the results. Nail deformities, cold intolerance, return to work, and the effect of sensory education were investigated. Comparison of crush and clean cut injuries did not yield any significant difference in any of the parameters. Patients who received sensory education had significantly better results in sensory testing. The results were classified as excellent, good, and poor based on results of two-point discrimination tests. The outcome was excellent in 18 fingers and good in 20 fingers. Overall, satisfactory sensory recovery was achieved in fingertip replantations without nerve repair.

Investigation of HSV-1, HSV-2, CMV, HHV-6 and HHV-8 DNA by real-time PCR in surgical resection materials of epilepsy patients with mesial temporal lobe sclerosis.

OBJECTIVE: The objective of this study is to investigate the presence of viral DNAs of HSV-1, HSV-2, HHV-6, HHV-8, and CMV in hippocampus of the patients with mesial temporal lobe epilepsy (MTLE) syndrome. METHODS: Pathological specimens were obtained from 33 patients with MTLE undergone temporal lobectomy with amygdalo-hippocampectomy due to intractable seizures. Autopsy materials from the hippocampus of 7 patients without neurological disease were used as controls. The data was also correlated with the clinical history of patients including febrile convulsions, age, and history of CNS infections. Real-time polymerase chain reaction method was performed for detection of DNAs of these viruses. RESULTS: HHV-6, HSV-1 and HHV-8 were detected in the hippocampus of 3, 2 and 1 patients with MTLE respectively. None of the hippocampus of patients with MTLE was positive for DNA of HSV-2 and/or CMV. Three patients with positive HHV-6 DNAs had febrile convulsions and family history for epilepsy. None of our control specimens showed PCR positivity to any of the 5 tested viruses. CONCLUSIONS: Our study is the first to report the presence of HHV-8 viral genome in the brain tissue of patient with MTLE. Viral DNAs were detected in a total of 18% of the patients in this study; we can conclude that activity of the latent virus in patients with hippocampal sclerosis should be more extensively studied to establish its role in active infection.