The effect of surgical factors on recurrence of tendon sheath giant cell tumours.

In this retrospective study, we evaluated the impact of tumour-related and surgical factors on the recurrence of giant cell tumours of tendon sheath. A total of 95 patients were treated at our institution between February 2012 and March 2021. We identified the factors most likely to be associated with recurrence from evaluation of classification, neurovascular invasion, bone erosion and joint invasion. Based on these criteria, we identified 49 patients with a high risk of recurrence. Of the 95 patients, recurrence was observed in 17. Among the 49 patients classified as high-risk, 13 were found to have recurrence. This study demonstrates that recurrence is more common in the high-risk patient group.Level of evidence: IV.

Comparing the outcomes of tripod technique and locked plate fixation for the treatment of Mason type 3 radial head fractures.

OBJECTIVES: In this study, we aimed to compare functional outcomes and complication rates of tripod technique and locked plate fixation used in Mason type 3 radial head fractures. PATIENTS AND METHODS: Between January 2012 and December 2019, a total of 27 patients (16 males, 11 females; median age: 43.2 years; range, 20 to 68 years) with Mason type 3 radial head fractures were retrospectively analyzed. The patients were divided into two groups according to fixation method used. Group 1 consisted of 12 patients who were treated with tripod technique, and Group 2 consisted of 15 patients who were treated with locked plate fixation. Operation time, follow-up period, length of hospital stay, union time, Disabilities of Arm, Shoulder and Hand (DASH) scores, range of motions and complications were recorded. RESULTS: The median time to bone union was 46.7 days in Group 1, which was significantly shorter than Group 2 (p<0.001). The median forearm pronation-supination arc was 123.75° (range, 30° to 180°) in Group 1 and was 94° (range, 45° to 180°) in Group 2. There was no significant difference in the forearm rotation between the groups. The median elbow flexion-extension arc was 99.17° (range, 65° to 130°) in Group 1 and was 80.33° (range, 30° to 130°) in Group 2. No statistically significant difference was found in the flexion-extension and pronation-supination arc degrees. There was no significant difference in the postoperative DASH scores between the groups (p=0.464). CONCLUSION: Our study results demonstrate that comparable results can be achieved in both techniques regarding functional outcome and range of motion. With a shorter union time and less complication rates, the tripod technique should be considered as the primary treatment method for the comminuted radial head fractures without a metaphyseal defect.

Comparison of Subungual Glomus Tumours in Terms of Nail Aesthetics and Recurrence According to Size and Location in the Germinal or Sterile Matrix.

PURPOSE: The aim of this retrospective study was to investigate the effect of subungual glomus tumour size and localization in the germinal or sterile matrix on tumour recurrence and aesthetic outcomes. PATIENTS AND METHODS: From 35 patients who underwent surgery for a subungual glomus tumour between February 2013 and February 2020, 26 patients - 17 women and 9 men - with 27 subungual glomus tumours fulfilled the inclusion criteria. The average age was 37.3 (22-58) years. According to the patients' surgical notes and preoperative magnetic resonance images 14 tumours were located in the sterile, 13 in the germinal matrix, and the mean size of the glomus tumours located in the germinal matrix was 4.9±1.7 mm, in the sterile matrix 3.6±1.0 mm. At the postoperative 12th month follow-up visit nail aesthetic was evaluated objectively according to Zook's fingernail appearance scoring. In addition, patients were asked to evaluate the pain and nail appearance in the involved finger by VAS (Visual Analog Scale 0-10). Patients who experienced recurrence were noted. RESULTS: No significant Zook's fingernail appearance score differences were observed between germinal and sterile matrix groups (p=0.097). Comparison of VAS score for pain and VAS score for nail appearance between the two groups also yielded similar values (p=0.449 and 0.395, respectively). The recurrence rate was similar at both locations (p=0.557) with 3 recurrences in the germinal, and 2 in the sterile matrix group. There was no relation between tumour size, Zook's fingernail appearance score (p=0.874) and recurrence (p=0.784). The observed germinal matrix glomus tumours were significantly larger than the sterile matrix tumours (p=0.031). CONCLUSION: Neither subungual glomus tumour size nor localization in the germinal or sterile matrices has different effects on nail appearance and recurrence.

Comparing the outcomes of fingertip-to-palm and fingertip-to-forearm two-stage flexor tendon reconstruction for isolated flexor digitorum profundus tendon injuries.

Flexor tendon injuries of the hand have devastating consequences when primary tendon repair fails or left untreated in the first place. Flexor tendon reconstruction is a substantial treatment option to obtain functional digit. In this study, we aimed to compare the functional outcomes and technical feasibility of fingertip-to-palm and fingertip-to-forearm tendon reconstruction methods. Thirty-five patients were divided into two groups according to the proximal attachment site of the free tendon grafts. Group I consisted of 18 patients whose tendon grafts were placed from fingertip-to-palm (zone III). Group II consisted of 17 patients whose tendon grafts were placed from fingertip-to-forearm (zone V). The mean of 39.6 months (range, 6-52 months) of follow-up with complete clinical data were obtained for all the cases. The mean length of the tendon grafts used in group I and group II was 9.7 ± 1.4 cm and 15.9 ± 1.2 cm, respectively. Significantly shorter tendon grafts were needed in group I (p < 0.001). Both mean DASH score and mean Michigan score were significantly improved postoperatively in both groups (p = 0.0001, p = 0.0001), but there was no significant difference between two groups based on postoperative DASH score (p = 0.112) and Michigan score (p = 0.151). No statistically significant difference was observed between two groups in terms of Strickland's scores (p = 0.868). This study demonstrates that comparable results can be obtained with fingertip-to-palm and fingertip-to-forearm staged tendon reconstructions. Fingertip-to-palm tendon reconstruction seems to be more advantageous when multiple flexor tendon injuries aimed to be reconstructed, in which requirement of tendon graft can be fulfilled with less donor site morbidity.Abbreviations: DASH: disabilities of the arm, shoulder and hand.

Pediatric infrafossal fracture of the humerus: A case series.

OBJECTIVES: In this case series, we aimed to evaluate the clinical and radiographic outcomes of the patients with infrafossal fracture of the humerus and to evaluate the upper extremity and elbow function with the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. PATIENTS AND METHODS: Between January 2005 and July 2020, the clinical data and radiographs of 2,443 children who were treated due to distal humerus fracture were retrospectively analyzed. A total of six patients (5 males, 1 female; mean age: 6.7±2.6 years, range, 3 to 11 years) treated due to an infrafossal fracture of the humerus were included. Radiographic measurements, such as Baumann's angle, lateral capitellohumeral angle, and carrying angle of the elbow, were performed. At the final follow-up, elbow joint range of motion (ROM) was measured, functional scores of the elbow and upper extremity were assessed. Complications were also recorded. RESULTS: The mean follow-up was 62.8±47.4 (range, 20 to 140) months. Two patients underwent open and three underwent closed reduction and internal fixation by different surgeons. One of the patients was treated with a long-arm cast. There was no major elbow ROM limitation. There was no significant deterioration in the lateral capitellohumeral and elbow carrying angles of the patients. Baumann's angle was normal for all the patients; however, it could not be measured in two patients, as their epiphyses were closed. Four patients had an excellent MEPS and two patients a good MEPS. The QuickDASH scores were low in all patients. There were two patients with cubitus varus who were treated surgically using lateral closing-wedge corrective osteotomy. CONCLUSION: Infrafossal fracture of the humerus is a fracture type which is different from supracondylar and transcondylar fractures and has not been previously reported in the literature. Despite the cubitus varus developed in two of our patients, functionally satisfactory results were achieved in all patients at the end of the treatment. Due to the risk of developing cubitus varus, patients with infrafossal fracture of the humerus should be followed closely until the end of adolescence. Although the current study is very limited in terms of being a guide for the treatment, it may contribute to the literature in terms of defining a new fracture subtype.

Comparison of Ultrasound-Guided Infraclavicular Brachial Plexus Block Sensorial Duration in Diabetic and Non-diabetic Patients: A Prospective Observational Study.

OBJECTIVE: Diabetic neuropathy is one of the most common complications of diabetes mellitus. Recovery from peripheral nerve blocks in diabetic patients with neuropathy may be delayed because of axonal degeneration and segmental demyelination. The aim of this study is to compare the infraclavicular brachial plexus block durations in patients with and without diabetes mellitus type 2. METHODS: This prospective observational study included 60 patients who were aged 40-80 years, with American Society of Anesthesiologists I-IV physical status and scheduled for elbow, forearm, and/or hand surgery under infraclavicular brachial plexus blocks. All 30 patients in Group DM (patients with diabetes mellitus type 2 diagnosis) and 29/30 patients in Group NODM (patients without diabetes mellitus diagnosis) completed the study successfully. The sensorial block duration was documented as the primary outcome, and the motor block duration, time-to-first pain, numeric rating scale scores at rest/during mobilization, rescue analgesic use, and total consumed doses through the first 2 postoperative days were all documented as the secondary outcomes. RESULTS: Sensorial block duration in Group DM (505 [315-1020] minutes) was longer than in Group NODM (440 [160-780] minutes) (P =.016). Motor block duration was also longer (488.7 ± 153.8 minutes vs 379.2 ± 118.9 minutes; P =.003), and time-to-first pain was prolonged (625 [360-1200] minutes vs 520 [300-900] minutes; P =.004) in Group DM. The highest NRS scores at the 6th hours, 12th hours, and rescue analgesic consumption through the first 2 postoperative days were lower in Group DM (P < .05). CONCLUSION: This infraclavicular brachial plexus block study highlights the current literature on diabetic patients with respect to longer block durations, prolonged time-to-first pain, lower pain scores, and less analgesic consumption.

ISOLATED CAPITELLAR FRACTURE FIXATION WITH HEADLESS SCREWS IN DIFFERENT CONFIGURATIONS.

Introduction: We evaluated the clinical and radiological outcomes of capitellar fractures treated with modified screw insertion (inserting the first fixation screw anteroposteriorly and the second screw posteroanteriorly), a technique that can be applied with a minimally invasive lateral elbow approach. Materials and Methods: Twenty-one isolated capitellum fractures that were surgically treated were included in the study. Fixation was achieved with two headless cannulated compression screws placed in anteroposterior and posteroanterior order using the modified lateral elbow approach. The Broberg-Morrey rating system was used to assess the post-operative functional status of the patients. Results: According to the Broberg-Morrey criteria, the mean score was 92.7 (77-100) and 13 cases had excellent, 7 had good, and 1 had fair results. None of the patients developed avascular necrosis or heterotopic ossification. According to the Broberg-Morrey arthrosis score, two cases had Grade 1 and one had Grade 2 arthrosis. One patient had a superficial wound site infection that was treated with antibiotics, and in one case a 60° extension loss was observed in the elbow. Conclusion: Treatment of isolated capitellar fractures with 2 headless screws placed anteroposteriorly and posteroanteriorly can provide stable fixation and is less traumatic for the elbow joint. Level of Evidence IV; Therapeutic Studies - Investigating the results of treatment.

Introdução: Avaliamos os resultados clínicos e radiológicos das fraturas do capítulo do úmero tratadas com a técnica de inserção de parafuso modificada (inserção do primeiro parafuso de fixação anteroposterior e do segundo parafuso posteroanterior), que pode ser aplicada com acesso lateral minimamente invasivo do cotovelo. Material e Método: Foram incluídas no estudo 21 fraturas isoladas do capítulo que foram tratadas cirurgicamente. A fixação foi obtida com dois parafusos de compressão canulados sem cabeça colocados em ordem anteroposterior e posteroanterior, usando acesso lateral modificado do cotovelo. O sistema de classificação Broberg-Morrey foi usado para avaliar o estado funcional pós-operatório dos pacientes. Resultados: De acordo com os critérios de Broberg-Morrey, o escore médio foi de 92,7 (77-100) e 13 casos foram excelentes, 7 bons e 1 regular. Nenhum paciente desenvolveu necrose avascular ou ossificação heterotópica. De acordo com o escore de artrose de Broberg-Morrey, dois casos tinham Grau 1 e um tinha artrose de Grau 2. Um paciente tinha infecção superficial da ferida, que foi tratada com antibióticos, e em um caso observou-se perda de 60° da extensão do cotovelo. Conclusão: O tratamento de fraturas isoladas do capítulo do úmero com 2 parafusos sem cabeça colocados anteroposterior e posteroanteriormente pode proporcionar fixação estável e é menos traumático para a articulação do cotovelo. Nível de evidência IV; Estudos terapêuticos - Investigação dos resultados do tratamento.

Thumb duplication classifications: Is there still a need for improvement?

OBJECTIVES: This study aims to compare the usefulness of two systems in classifying thumb duplication cases and give some examples of the cases we believe that are unclassifiable. PATIENTS AND METHODS: Between January 2011 and January 2018, a total of 50 patients (29 males, 21 females; median age: 46.4±68.3 months; range, 1 to 318 months) with thumb duplications as assessed according to the Wassel and Rotterdam classification systems were included. RESULTS: Duplication was present in the right hand in 28, in the left hand in 21, and in both hands in one patient. According to the Wassel classification system, 45 patients could be allocated in any of the types; however, five patients could not be classified. According to the Rotterdam classification, 47 cases fell into one of the classifications; however, three cases could not be classified. CONCLUSION: Despite efforts to find the best classification system for thumb duplications, the proposed systems may not fully cover the presented radial polydactyly cases, and additions to the system are required.

Clinical results of free vascularized fibula graft in the management of precollapse osteonecrosis of the femoral head: A retrospective clinical study.

OBJECTIVE: This study aimed to evaluate clinical results, femoral head survival, and the need for total hip arthroplasty (THA) in patients with precollapse osteonecrosis of the femoral head (OFH) (Steinberg stage II and III) treated by free vascularized fibula graft (FVFG) application. METHODS: We retrospectively reviewed 54 hips of 47 patients (39 males, eight females; mean age 36 ± 14 years) who underwent FVFG due to OFH, with at least two years of follow-up. The patient data, including Harris Hip Score (HHS), Visual Analogue Scale (VAS), and conversion to THA, were documented. RESULTS: The right hip of 26 patients and the left hip of 28 patients were involved. Bilateral FVFG surgery was performed on seven patients due to bilateral OFH. The mean follow-up time was 5.5 (range 2-14) years. Survival of the femoral head was observed in 39 hips (72.2%), while the femoral head collapse was observed in 15 femoral heads (27.8%). The mean preoperative HHS increased from 46.5 (range=12-85) to 86.5 (range=33-100) postoperatively (P < 0.001). The mean preoperative VAS score improved from 8.2 (range=2-10) to 1.3 (range=0-10) postoperatively (P < 0.001). THA was performed on seven hips at a mean follow-up time of 1.8 years (range=0.7-3.3). There was no significant difference in the collapse rate between unilateral or bilateral OFH (P=0.175). A higher survival rate was observed in the Steinberg stage II femoral head patients compared to the stage III femoral head (P=0.021). CONCLUSION: This study has shown that FVFG surgery can be a good option for managing patients with Steinberg stage II and III precollapse OFH to prevent femoral head collapse and joint function. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Use of Corrective Ulnar Osteotomy and Radial Head Relocation Into Preserved Annular Ligament in the Treatment of Radiocapitellar Instability Secondary to Pediatric Chronic Monteggia Fracture-Dislocation.

PURPOSE: Opening-wedge osteotomy of the ulna restores normal ulnar length and corrects the angulation of the ulna in patients with chronic Monteggia fracture-dislocations. In addition, this eases the reduction of the radial head. Morbidity caused by annular ligament reconstruction surgery can be prevented by preserving the intact annular ligament. After dilatation and mobilization of the annular ligament, reduction of the radial head can be accomplished. This study evaluated the effectiveness of corrective opening-wedge ulnar osteotomy and radial head relocation into the intact annular ligament in the treatment of radiocapitellar instability secondary to pediatric chronic Monteggia fracture-dislocation. METHODS: Fourteen patients diagnosed with radial head dislocation associated with plastic deformation of the ulna or ulnar fracture were included in the study. Radiologic and clinical results of these patients who underwent corrective ulnar osteotomy and radial head relocation into an intact annular ligament were evaluated retrospectively. RESULTS: The mean age of the patients at the time of injury was 7.4 years (range, 3 years to 12 years). The average time between the injury and surgery was 19.1 months (median, 8 months; range, 3 months to 66 months); the average follow-up period was 28.7 months (range, 12 months to 60 months). The mean Kim score was 69.6 (range, 50 to 75) preoperatively and 92.9 (60 to 100) at last follow-up. According to Kim score, the results were considered excellent in 12 cases and poor in 2 cases. Radial head subluxation recurred in 2 separate cases. In addition, chondrolysis changes were seen in 1 case. Reduction loss and osteoarthritic changes in the radiocapitellar joint were considered poor results in follow-up radiographs. CONCLUSIONS: Corrective ulnar osteotomy and relocating the radial head into the intact annular ligament can be safely used for treating chronic Monteggia fracture-dislocation cases without radial head and capitellum deformity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Isolated capitellar fracture fixation with headless screws in different configurations / Fixação de fratura isolada do capítulo do úmero com parafusos sem cabeça em diferentes configurações

ABSTRACT Introduction We evaluated the clinical and radiological outcomes of capitellar fractures treated with modified screw insertion (inserting the first fixation screw anteroposteriorly and the second screw posteroanteriorly), a technique that can be applied with a minimally invasive lateral elbow approach. Materials and Methods Twenty-one isolated capitellum fractures that were surgically treated were included in the study. Fixation was achieved with two headless cannulated compression screws placed in anteroposterior and posteroanterior order using the modified lateral elbow approach. The Broberg-Morrey rating system was used to assess the post-operative functional status of the patients. Results According to the Broberg-Morrey criteria, the mean score was 92.7 (77-100) and 13 cases had excellent, 7 had good, and 1 had fair results. None of the patients developed avascular necrosis or heterotopic ossification. According to the Broberg-Morrey arthrosis score, two cases had Grade 1 and one had Grade 2 arthrosis. One patient had a superficial wound site infection that was treated with antibiotics, and in one case a 60° extension loss was observed in the elbow. Conclusion Treatment of isolated capitellar fractures with 2 headless screws placed anteroposteriorly and posteroanteriorly can provide stable fixation and is less traumatic for the elbow joint. Level of Evidence IV; Therapeutic Studies - Investigating the results of treatment.

RESUMO Introdução Avaliamos os resultados clínicos e radiológicos das fraturas do capítulo do úmero tratadas com a técnica de inserção de parafuso modificada (inserção do primeiro parafuso de fixação anteroposterior e do segundo parafuso posteroanterior), que pode ser aplicada com acesso lateral minimamente invasivo do cotovelo. Material e Método Foram incluídas no estudo 21 fraturas isoladas do capítulo que foram tratadas cirurgicamente. A fixação foi obtida com dois parafusos de compressão canulados sem cabeça colocados em ordem anteroposterior e posteroanterior, usando acesso lateral modificado do cotovelo. O sistema de classificação Broberg-Morrey foi usado para avaliar o estado funcional pós-operatório dos pacientes. Resultados De acordo com os critérios de Broberg-Morrey, o escore médio foi de 92,7 (77-100) e 13 casos foram excelentes, 7 bons e 1 regular. Nenhum paciente desenvolveu necrose avascular ou ossificação heterotópica. De acordo com o escore de artrose de Broberg-Morrey, dois casos tinham Grau 1 e um tinha artrose de Grau 2. Um paciente tinha infecção superficial da ferida, que foi tratada com antibióticos, e em um caso observou-se perda de 60° da extensão do cotovelo. Conclusão O tratamento de fraturas isoladas do capítulo do úmero com 2 parafusos sem cabeça colocados anteroposterior e posteroanteriormente pode proporcionar fixação estável e é menos traumático para a articulação do cotovelo. Nível de evidência IV; Estudos terapêuticos - Investigação dos resultados do tratamento.

A new custom-made plate preparation method for bony mallet finger treatment and a comparison with extension block technique.

OBJECTIVES: In this study, we aimed to describe a new hook plate technique (HPT) and to compare our results with the conventional extension block technique (EBT) with a Kirschner wire (K-wire) for bony mallet finger treatment. PATIENTS AND METHODS: Between April 2015 and January 2018, a total of 19 patients including 10 who were treated with EBT (7 males, 3 females; mean age: 30.1±7.3 years; range, 17 to 48 years) and nine who were treated with HPT (6 males, 3 females; mean age: 31.7±11.3 years; range, 19 to 42 years) for bony mallet finger with distal interphalangeal (DIP) joint subluxation and/or fracture fragment larger than one-third of distal phalanx (Wehbe-Schneider type 1/b, 2/a, 2/b, 3/a) joint were retrospectively analyzed. The DIP range of motion (ROM), Warren and Crawford scores, time to return to work/daily activity, operation time, the number of fluoroscopy shots, cost and complications were compared. RESULTS: No significant difference was found in the DIP ROM (p=0.708) and the Warren/Norris and Crawford scores (p=0.217 and p=0.175, respectively) between the two groups. Operation time and material cost were higher with HPT (p=0.006, p=0.001). There was no significant difference in the number of fluoroscopy shots (p=0.344). Although DIP joint motion was started at two weeks in the HPT group and at eight weeks in the EBT group, no significant difference was observed in the time of return to work and normal daily life in both groups (p=0.859). Complications were observed in two patients in the EBT group and in three patients in the HPT group. No significant difference in total complications was observed between the two groups (p=0.666). CONCLUSION: Bony mallet finger treatment with a custom-made hook plate prepared from 1.3-mm AO plates appeared to be clinically and radiologically similar to EBT. Additionally, HPT had the advantages of allowing early ROM to DIP joint and eliminating the need for a secondary surgery such as K-wire removal. On the other hand, hardware cost with HPT was higher than EBT.

Comparison of clinical and radiological results of fixation methods with retrograde intramedullary Kirschner wire and plate-screw in extra-articular metacarpal fractures.

OBJECTIVES: In this study, we aimed to compare clinical and radiographic outcomes of retrograde intramedullary Kirschner-wire (K-wire) fixation with those of plate-screw (PS) fixation. PATIENTS AND METHODS: A total of 98 metacarpal shaft fractures in 75 patients (65 males, 10 females; mean age: 31.2±10.9 years; range, 16 to 65 years) were included between January 2011 and December 2017. The total joint active range of motion (AROM) and grip strength of the healthy and broken hands were evaluated. The Visual Analog Scale (VAS) and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores were recorded. We compared surgery duration, number of fluoroscopy images, and cost-effectiveness for each technique. RESULTS: The overall mean follow-up was 21.9 (range, 12 to 56) months. At the last follow-up, total joint AROM (p=0.072), VAS score (p=0.298), QuickDASH score (p=0.132), and hand grip strength (p=0.947) were similar between the groups. Radiological union occurred in the PS and K-wire groups in a mean of 5.84 (range, 3 to 8) and 4.46 (range, 3 to 20) weeks, respectively (p=0.173). A significant difference was found in surgery duration (p=0.021) and number of fluoroscopy images (p<0.05) between the PS and K-wire groups. Two wound complications were observed in the PS group and one with K-wires. CONCLUSION: Retrograde intramedullary K-wire fixation has certain advantages such as being less invasive and more accessible with shorter operation time, compared to PS fixation. Similar radiological and clinical scores can be obtained in patients undergoing retrograde intramedullary K-wire fixation or PS fixation.

Epiphysis Salvage Reconstruction and Associated Complications Following Tumor Resections in Skeletally Immature Patients.

The purpose of this study was to discuss the epiphysis salvage reconstruction procedure outcomes and complications in skeletally immature patients. The study included 12 patients with pediatric malignant tumors (osteosarcoma, Ewing's sarcoma) located close to the epiphysis, who underwent epiphyseal-preservation surgery with vascularized fibula in the plastic surgery and orthopedics and traumatology clinic between January 2008 and November 2018. The study was designed retrospectively. Neoadjuvant and adjuvant chemotherapy was administered to all patients. None of the patients received radiotherapy. Functional evaluation was assessed using the Musculoskeletal Tumor Society (MSTS) scoring system. The patients were followed up for a mean period of 51 (21­115) months. The mean age of patients was 10.4 (range, 5 to 15) years. Union times in the target region (epiphyseal region) and diaphyseal region were reported separately. Accordingly, the mean total union time in the target region of all patients was 7.9 months (5­11), and the mean total union time in the diaphyseal region was 6.5 months (5­9). According to the MSTS grading system, the mean score of the patients was 27.50 (range, 21­30). The mean operative time was 480 (390­540) min, the mean intraoperative blood loss was 790 (580­1100) cc, and the mean length of hospital stay was 6 (4­17) days. Six patients had shortness, 5 patients had delayed union, 3 patients had angular deformity, and 2 patients had infection. Epiphyseal-preservation surgery may be an alternative to other techniques used for malignant tumors located close to the growth line in skeletally immature patients. Despite the fact that this technique has plenty of complications, many of them can be successfully treated with secondary operations without leaving sequelae.

[The Importance of Mycological Diagnosis: A Scedosporium apiospermum Complex Mycetoma Case Neglected For 20 Years]. / Mikolojik Taninin Önemi: 20 Yil Ihmal Edilen Bir Scedosporium apiospermum Kompleks Miçetoma Olgusu.

Scedosporium apiospermum complex members are opportunistic fungi that can be found in environments such as soil and polluted water. In this report, we aimed to present a case of mycetoma caused by Scedosporium apiospermum complex that developed in a 40-year-old female patient with immunocompetent system and diagnosed by fungal culture. In the anamnesis of the patient who admitted in 2015 with the complaint of more than one fistulized discharge wound, pain and swelling in the dorsal of the right hand and wrist; it was learned that her complaints started about 20 years ago with a slight swelling on the back of the wrist, and when it worsened, the abscess was drained and antibiotic treatment was initiated in a private surgical center. However, it was learned that she did not benefit from the treatments, and over time, fistulized, yellow-discharged wounds appeared on the back of her hand and wrist, and she had undergone various surgical interventions and used antibiotics. Routine laboratory tests of the patient, who did not have an underlying chronic disease, were normal. Magnetic resonance imaging (MRI) and X-ray findings were compatible with osteomyelitis and 'dot in circle' sign seen on MRI was characteristic for mycetoma. Pathological examination was interpreted as active chronic inflammatory reaction in the soft tissue and chronic osteomyelitis. Mycobacteria, bacteriological and fungal cultures of the two biopsy samples taken during surgical debridement and one month later were performed. Bacteriological and mycobacterial cultures were negative, while Scedosporium genus grew in the fungal cultures of the both samples. Isolates were identified as Scedosporium apiospermum/Pseudallescheria boydii with MALDI Biotyper (Bruker Daltonics, Bremen, Germany) system and Scedosporium boydi by sequence analysis of the ITS region. The antifungal susceptibility tests were performed according to CLSI M38-A2 criteria, and were evaluated at the 72nd hour. The minimum inhibitory concentration (MIC) values of fluconazole, caspofungin, amphotericin B, itraconazole, vorikonazole, posaconazole and isavuconazole were > 64 µg/ml, 16 µg/ml, 4 µg/ml, 16 µg/ml, 0.25 µg/ml, 2 µg/ml and 0.25 µg/ml, respectively. Voriconazole and terbinafine treatment was initiated. In the control performed in the 9th month of the treatment, it was observed that the complaints of discharge, pain and swelling were resolved, pain and swelling complaints were recovered, fistula tracts were closed and joint movements were painless. In the control MRI performed at 15th and 18th months, it was observed that there was no soft tissue involvement and the findings were compatible with osteoarthritis after infective osteomyelitis. This case whose longterm complaints improved with mycological diagnosis and appropriate treatment; reveals the importance of keeping mycological diagnosis in mind in chronic bone and soft tissue infections. Identifying the fungus to the genus and species level and arranging the treatment according to the antifungal susceptibility test results are very important in patient management.

Functional Improvement with Free Vascularized Toe-to-hand Proximal Interphalangeal (PIP) Joint Transfer.

BACKGROUND: Reconstruction of small joints of fingers is still challenging in hand surgery. Implant arthroplasty and arthrodesis have some limitations in the reconstruction of small finger joints. Free vascularized PIP joint transfer from second toe to finger is a promising autogenous reconstructive alternative. METHODS: In this prospective study, 7 cases of free vascularized PIP joint transfer were analyzed. The measurements for active and passive range of motion (ROM), grip, and pinch strength has been done preoperatively and 1-year postoperatively. The functional change in daily life quality and work-related activities was evaluated with Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. RESULTS: Mean follow-up period was 20.3 months (12-25). Preoperative mean active and passive ROM values were 3.6° (0-14°) and 11.9° (0-29°), respectively. Postoperative 1-year measurements revealed a mean active ROM of 24.1° and a mean passive ROM of 31.6°. Mean grip and pinch strength increased from 52.1 to 58.6 lbs and from 5.1 to 5.9 lbs, respectively. Mean preoperative and postoperative DASH-scores were 41.3 and 30.3. CONCLUSION: The improvement in ROM, increasing grip strength, and declining DASH scores in our study support that free vascularized joint transfer improves patients' daily life quality and work-related activities via providing a functional joint if performed with appropriate indications, careful planning, and meticulous surgical execution. Free vascularized joint transfer provides an autogenous, painless, mobile, and stable joint. It also has the advantages of composite tissue reconstruction and lacks the disadvantages of arthrodesis and synthetic joint implants.

Fracture lines and comminution zones in OTA/AO type 23C3 distal radius fractures: The distal radius map.

OBJECTIVE: This study was designed to define fracture lines and comminution zones in OTA/AO 23C3 distal radius fractures from axial computed tomography (CT) images that would influence surgical planning, development of new classifications, and possible implant designs. METHODS: Thirty-four consecutive OTA/AO 23C3 fractures treated by a single surgeon between January 2014 and December 2014 were analyzed. For each fracture, maps of the fracture lines and zones of comminution were drawn. Each map was digitized and graphically superimposed to create a compilation of fracture lines and zones of comminution. Based on this compilation, major and minor fracture lines were identified and fracture patterns were defined. RESULTS: All major fracture lines were distributed in the central region of the radius distal articular surface. There is a recurrent fracture pattern with a comminution zone including the scaphoid and lunate fossa; Lister's tubercle; and ulnar, volar, and radial zones. CONCLUSION: It is important for the practicing surgeon to understand these four main fragments. Knowledge of this constant pattern should influence the development of new classifications and possible implant designs.

Comparison of the Cost and Efficacy of Axillary Anesthesia and Wide-Awake Anesthesia in Finger Surgeries.

OBJECTIVES: Wide-awake anesthesia is a type of local anesthesia consisting of a combined application of lidocaine, epinephrine, and bicarbonate and has a wide potential in hand surgery as it offers the advantage of being applied without sedation and without using a tourniquet. In light of recent studies, its use has increased with the disappearance of the belief among surgeons that epinephrine can cause circulatory disturbance in fingers. METHODS: Patients with finger pathologies who were operated upon at the Baltalimani Bone Diseases Teaching and Research Hospital between January 2015 and February 2016 were divided into two groups according to anesthesia type: wide-awake anesthesia and axillary block anesthesia, with 52 patients in each group. Start time of surgery, length of hospital stay, anesthesia cost, and patient satisfaction were compared. For the evaluation of patient satisfaction, the patients were postoperatively asked whether they would accept the same anesthesia method if they had to have the same experience. Each group was further divided into two subgroups: bone interventions (phalangeal fracture, bone biopsy, implant removal, and interphalangeal joint arthrodesis) and soft tissue interventions (digital nerve repair, fingertip local skin flap, flap division, releasing stiff joint, ligament repair, and debridment). Each subgroup included 26 patients. RESULTS: Sufficient anesthesia to cover the whole duration of surgery was achieved in both the groups. Regarding the question "If you were experiencing the same experience, would you accept the same anesthesia again?" 26 and 33 patients responded positively, 16 and 7 patients repsonded negatively, and 10 and 12 patients remained neutral in the axillary block and wide-awake anesthesia groups, respectively. According to the Social Security Institution data, the average anesthesia cost was 316.1 TL in the axillary block anesthesia group and 25.3 TL in the wide-awake anesthesia group; the average length of hospital stay was 32.9 h in the former and 13.6 h in the latter. Start time of surgery was 34 minutes in axillary block anesthesia and 5.3 minutes in wide-awake anesthesia. CONCLUSION: We found that compared with axillary block anesthesia, the length of hospital stay was 19.3 h less and anesthesia cost was 290.8 TL less with wide-awake anesthesia; furthermore, the start time of surgery decreased by 29.7 min with the latter. Moreover, patient satisfaction rate was better in the wide-awake anesthesia group. No bleeding, patient incompatibility, and other complications that might interfere with the surgery were detected .

Extracorporeal Shock Wave Therapy in Dupuytren's Disease.

OBJECTIVES: We investigated the use of extracorporeal shock wave therapy (ESWT) in patients with Dupuytren's Disease (DD) palmar nodules in an attempt to reduce the contracture, alleviate the pain (if any), increase the range of motion and quality of life, and delay a probable surgery in the long term. METHODS: Patients with DD who presented to our hand surgery clinic and fulfilled the inclusion criteria were enrolled. The treatment was performed by the same physician using the ESWT device once a week for six weeks. The patients were evaluated with the VAS score, Quick-DASH questionnaire, and MAYO wrist score, and their grip strength was measured using a Jamar dynamometer. RESULTS: The mean age of the 23 patients included in the study was 51 years. There was a significant improvement in the second measurement of VAS and DASH scores compared with the preoperative values. The increase in the second and final follow-up measurements of the MAYO score and grip strength results compared with the preoperative values was found significant. The table-top test results turned negative in 16 patients. CONCLUSION: We can suggest that ESWT in the early term can be preferred over costly injections and surgical intervention options as it increases the quality of life and delays the recurrence of contractures.