The results of delayed open reduction and internal fixation in chronic bony mallet finger injuries.

OBJECTIVES: The aim of this study was to evaluate the functional results of delayed open reduction and Kirschner wire (K-wire) fixation procedures in patients with delayed presentation of bony mallet finger. PATIENTS AND METHODS: Between February 2009 and November 2019, a total of 19 patients (15 males, 4 females; median age: 24.8 years; range, 14 to 47 years) who were diagnosed with a delayed bony mallet finger and treated with dorsal block pin, direct pinning, or the umbrella handle technique were retrospectively analyzed. The Crawford criteria were used to evaluate the outcomes. The degrees of range of motion (ROM) were measured by a goniometer. RESULTS: The median time from injury to surgery was 41 (range, 28 to 90) days. The median DIP joint extension limitation was 7.63 (range, 0 to 40) degrees and the median ROM of the DIP joint was 66.3 (range, 20 to 90) degrees. There was no statistically significant difference in the postoperative ROM, compared to the uninjured side (p>0.05). The Crawford score was excellent in 11, good in four, fair in three, and poor in one patient. Bone union was achieved in all patients. CONCLUSION: Delayed open reduction and K-wire fixation of chronic bony mallet finger injuries yield successful functional outcomes with low complication rates. Extension lag can be eliminated in most patients by making the joint surface anatomical. The most optimal method should be selected depending on the size of the fracture fragment.

Reconstruction of mutilating hand injuries by microsurgical free tissue transfers from the foot.

INTRODUCTION: The aim of this study is to present various hand reconstruction methods and provide technical notes regarding the treatment of mutilating hand injuries using free-tissue transfers from the foot and to investigate whether these transfers provide patients with a usable hand or not. PATIENTS AND METHODS: Ninety patients with mutilating hand injuries were included in the study. A total of 101 procedures were performed. Patients were contacted by phone to evaluate their working status and to record any complaints regarding their donor sites. The Quickdash questionnaire was conducted for the 53 patients who could be reached. Operative techniques, secondary procedures, finger survival, and physiotherapy data were noted retrospectively. RESULTS: In 36 patients, a trimmed great toe was transferred to the thumb. Second toe-to-thumb transfers were performed in 8 patients, and second toe-to-finger transfers were performed in 10 patients. In 13 patients, 2 toes from one side were transferred, and in 6 patients, 3 toes were transferred to the hand. Bilateral toe transfers were performed in 9 patients. Eight patients underwent joint transfers, of which 2 involved joint transfers from both feet. The overall finger survival rate for the transfer procedures was 95.04%. The average Quickdash score of the patients who could be reached (n = 53) was 27.49, with 62.3% of the patients being able to use their hands in their previous jobs, and 26.4% needing to change their jobs because of their hand injuries. 41.5% of the patients had no donor site complaints. 47.2% had mild complaints, and 11.3% had major donor site complaints. CONCLUSION: Multiple-toe transfer techniques along with flap coverage options should be considered, and delicate planning is mandatory to achieve at least a basic or acceptable hand. Three toes, including the great toe, can be transferred in a single operation by dissecting both the dorsal and plantar arterial systems. Crush injuries of the dorsal side of the hand may be reconstructed using combined transfers of bones, joints, extensor tendons, and skin. In our series, 88.7% of patients with mutilating hand injuries were able to return to work after we performed tissue transfers from the foot.

Survival and Comparison of External Bleeding Methods in Artery-Only Distal Finger Replantations.

PURPOSE: If there are no veins available in a distal amputation, an artery-only replantation is performed, and an external bleeding method is commonly used. We conducted a survival analysis in a large series of artery-only replantations and compared 2 different external bleeding methods in artery-only distal replantations: nail matrix or hyponychial area bleeding and pulp skin area bleeding, which we have called the crater method. METHODS: Two hundred twenty-eight artery-only distal finger replantations in 199 patients were included in the study. The replanted digits were divided into 2 groups according to the external bleeding methods. One group (n = 94; 41.2%) included the patients in whom the external bleeding was performed using a traditional nail bed incision and the second group (n = 134; 58.8%) included the patients in whom external bleeding was performed using the crater method. The finger survival rates and postoperative circulatory problems were examined. The impact of the injury mechanism, injury level, and external bleeding method on survival were evaluated. RESULTS: Clinical findings indicating venous insufficiency were observed in 198 (86.8%) replanted fingers. One hundred eighty-two (79.8%) survived, and complete necrosis developed in 46 (20.2%). Viability was maintained in 84% of patients treated with the nail bed bleeding method and 76.9% of patients treated using the crater method. Clean-cut cases had the best results and subzone 3 cases had the worst results. CONCLUSIONS: The artery-only replantation was associated with a 79.8% survival rate. The method of achieving venous outflow did not appear to have an impact on survival. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Techniques and survival incidence for revascularization of degloved fingers.

We report techniques and survival incidence of three subtotally and nine completely degloved fingers in seven patients. We performed end-to-end arterial repairs in seven fingers, vein graft repairs for arteries in two fingers, arteriovenous anastomoses in three fingers. End-to-end vein anastomosis was performed in all fingers. One finger requred re-exploration. Soft tissues in the eight degloved fingers survived completely, two failed completely, and two were partially necrotic. We conclude from our results that following revascularization, the skin from a completely degloved finger skin will survive in approximately two cases out of three. LEVEL OF EVIDENCE: IV.

Surgical reconstruction in Wassel type IV thumb duplication.

OBJECTIVE: The aim of this study was to review the results of patients with Wassel type IV thumb duplication, treated with a single reconstructive procedure. METHODS: The mean follow-up period was 76.9 months. Objective assessments were carried out using Horii modification of Tada scoring system and ALURRA scoring system. Thumb length, thumb girth, range of motion of metacarpophalangeal (MCP) and interphalangeal (IP) joints and angular deformities at MCP and IP joints were evaluated. RESULTS: The mean ALURRA score was 21 (range; 16-24) and Tada Score 5.25 (range; 2-7). The length of the operated thumb was approximately 95%, the girth 89% and nail width 80% of the non-operated side. The mean range of motion was 75.1% of the unaffected thumb in interphalangeal joint and 80.1% in metacarpophalangeal joint. Metacarpophalangeal joint malalignment had shown statistically significant negative correlation with the scores of Tada, ALURRA and VAS. CONCLUSION: Surgical reconstruction may provide a functional and stable thumb in Wassel type IV thumb duplications. The satisfaction of patients is affected by angular deformity of thumbs and cosmetic outlook.

Peroneal nerve injury surgical treatment results.

OBJECTIVE: The purpose of this study was to retrospectively evaluate the clinical and functional results of nerve grafting and end-to-end peroneal nerve repair between sciatic bifurcation and distal branching. METHODS: The study included 26 patients (22 men, 4 women; mean age: 19.9 years; range: 5 to 46 years) who underwent peroneal nerve repair between 1992 and 2009. Open nerve injuries were seen in 21 patients and closed injuries in 5. Surgical repair was performed with sural nerve grafting in 19 patients and end-to-end in 7. Mean nerve graft length was 5.42 (range: 2 to 15) cm with a mean 3.1 (range: 2 to 4) nerve cables used. Mean follow-up was 33 (range: 13 to 96) months. The British Medical Research Council (BMRC) scale was used for the evaluation of the tibialis anterior and peroneal muscles and Semmes-Weinstein monofilaments were used for protective sensation evaluation. RESULTS: Adequate and full recovery was observed in 19 patients (73%). Mean follow-up time was 39.3 months in patients undergoing nerve grafting and 30.1 months in end-to-end nerve repair. Fifteen of 19 patients with nerve grafting and 4 of 7 patients with end-to-end nerve repair had an adequate or full recovery. Posterior tibial tendon transfer to dorsal foot was applied in 3 of 7 patients without recovery. Protective sensory recovery was determined in 16 of 22 patients. CONCLUSION: Good results in both end-to-end repair and in repair with grafting is possible in peroneal nerve repair.

The results of reverse-flow island flaps in pulp reconstruction.

OBJECTIVE: The aim of this study was to retrospectively review the results of homodigital reverseflow proximal or middle phalanx dorsal skin island flaps. METHODS: We reviewed the overall results of 67 dorsal skin flap reconstructions performed on 61 proximal phalanxes and 6 middle phalanxes at our hospital during an 11 year period. The results were evaluated with static two point discrimination, Semmes-Weinstein monofilament test, occurrence of nail deformities, loss of interphalangeal joint motion, scar appearance of flap donor area, the incidence of vascular insufficiency in postoperative period, and subjective evaluation of patient satisfaction. RESULTS: The highest incidence of defect types were palmar oblique pulp defects in 18 patients (26.8%), transverse pulp defects in 16 patients (23.8%), and hemipulp oblique amputations in 11 patients (16.4%). Crush injuries were the cause of injury in 66% of patients. The average followup time was 40 months and long-term results were available in 21 patients. Total necrosis of flap in one patient (1.4%), superficial epidermolysis in 4 patients (5.9%), and nail deformity in 4 patients (5.9%) were seen. According to Semmes-Weinstein monofilament test results, protective sensation was achieved in 76% of patients. Static two point discrimination data showed variable distribution between 2 mm and 11 mm. The subjective patient satisfaction level was 95%. CONCLUSION: Homodigital reverse-flow proximal or middle phalanx dorsal skin island flaps give satisfactory cosmetic and sensorial results outside the pinch area, even if the dorsal branch of the digital nerve is not included.

Results of partial matrixectomy for chronic ingrown toenail.

BACKGROUND: Several treatment modalities which targeted partial matrixectomies, including chemical, laser matrixectomy, and partial nail avulsion, have been used in the dermatology, podiatry, and orthopaedic literature. We report our experience with surgical matrixectomy. METHODS: We treated 224 patients with severe ingrowing toenails. Segmental wedge resection of involved margin was performed. Followup time was a minimum of 10 months. RESULTS: Statistical analysis of recurrence and disease parameters such as stage of disease, infection, involved margin, previous surgery, followup time, and age showed no significant correlation (p>0.05). Twenty-two patients (9.8%) had a recurrence. Revision surgery was performed in 16 patients (7.1%). CONCLUSION: We recommend the Winograd technique with a few modifications especially for severe Stage 2 and 3 cases. Both loupe magnification and observation of soft tissue in the postoperative period were important details.

Long-term functional results after radial nerve repair.

OBJECTIVE: This study aimed to evaluate the functional results of end-to-end repairs in radial nerve injuries. METHODS: The study included 18 (15 males, 3 females) patients who underwent middle level end-to-end radial nerve repair and who responded to our final follow-up call. Patients' average age was 30 (range: 16 to 43) years. The average time lapse between injury and repair was 25.1 days (range: 1 day to 13 months). Pinch and grip strength measurements were graded according to the modified Verga classification. The Highet classification was used for the evaluation of sensorial recovery. Functional outcome were assessed with the DASH-T score. Average follow-up time was 62.5 (range: 24 to 156) months. RESULTS: Motor function according to the Verga classification was excellent in 16 patients and poor in two. Pinch and grip power measurement comparison of the two sides in the 16 patients with excellent results showed a respective 24.1% and 14.3% decrease on the affected side. According to Highet's classification, sensorial evaluation was S4 in seven patients, S3+ in four, S3 in three, S2+ in one, S2 in one, and S1 in two patients. The average DASH-T score of patients with excellent results was 7.3. CONCLUSION: Radial nerve repairs, if done end-to-end using an appropriate technique, may lead to nearly full recovery in younger patients.

Ultrasonographic evaluation of the iatrogenic peripheral nerve injuries in upper extremity.

The aim of our study is to assess the efficiency of the ultrasonography (US) in the diagnosis of peripheral nerve injury. This study includes nine patients (six radial, one median and two posterior interosseous (PIO) nerves) with peripheral nerve injury diagnosed by clinical and electrophysiological methods in the last 3 years. Preoperatively, an ultrasonographic examination was performed and correlated with physical exam and surgical findings. Five patients, who were diagnosed as peripheral nerve transection by US, underwent surgery. The ultrasonographic findings were concordant with the intraoperative findings. Axonal swelling alone was found in the remaining three patients, who were treated conservatively because of preserved nerve continuity without display of nerve compression. In one patient, we were unable to visualize the nerve due to obesity and soft tissue edema. High-resolution US provide morphological information about the exact location, intensity and extent of the nerve injuries, facilitating the preoperative diagnosis. Thus, US may be a useful method for planning optimal treatment strategy in especially iatrogenic nerve injuries.

[The importance of patient selection for the treatment of proximal humerus fractures with percutaneous technique]. / Proksimal humerus kiriklarinda perkütan tespit için hasta seçiminin önemi.

OBJECTIVES: We evaluated the indications and disadvantages of percutaneous technique for proximal humerus fractures in relation to complications encountered in osteoporotic elderly patients and the importance of patient selection. METHODS: The study included 18 patients (10 men, 8 women; mean age 48 years; range 14 to 89 years) who underwent percutaneous fixation (closed reduction and pin fixation with K-wires or Schanz screws) for proximal humerus fractures. Eight patients were beyond 60 years of age. According to the Neer classification, five patients had two-part, 13 patients had three-part neck fractures. The patients were evaluated with range of motion of the shoulder, radiographs, and the Disability of Arm Shoulder and Hand questionnaire (DASH). The mean follow-up was 23 months (range 8 to 60 months). RESULTS: The mean shoulder abduction was 134 degrees (range 30 degrees to 160 degrees) and the mean elevation was 118 degrees (range 30 degrees to 140 degrees). Full range of motion of the shoulder was achieved in 11 patients (61.1%), including all with two-part fractures. Abduction losses of 60 degrees to 130 degrees and less than 30 degrees were seen in four patients and three patients, respectively, all of whom were older than 60 years. The mean DASH score was 18 (range 0 to 77). Fourteen patients having a score of less than 10 had no pain or functional complaints. Four patients with a score of more than 10 were older than 70 years. Pin migration was observed in seven patients (38.9%), all of whom were over 60 years of age. One patient required revision with partial prosthesis. Nonunion was seen in one patient (5.6%) and malunion with a varus/valgus deformity occurred in four patients (22.2%). None of the patients developed avascular necrosis. CONCLUSION: Percutaneous fixation may be preferred in the treatment of two-part and carefully-selected three-part proximal humerus fractures. Due to high complication rate, patient selection is of primary importance among elderly patients.

[Comparison between two mini incision techniques utilized in carpal tunnel release]. / Açik karpal tünel gevsetmesinde iki farkli mini kesi yönteminin karsilastirilmasi.

OBJECTIVES: We compared two mini skin incision techniques utilized in the treatment of carpal tunnel syndrome (CTS). METHODS: Twenty-seven patients who underwent surgery for CTS were evaluated in two groups according to the site of the mini incision performed for surgical release. A single mini skin incision was performed over the transverse carpal ligament in 12 patients (group 1; 17 hands; 1 man, 11 women; mean age 55 years; range 38 to 66 years), and on the distal side of the ligament in 15 patients (group 2; 17 hands; all women; mean age 54 years; range 34 to 71 years). The two groups were compared with regard to improvement in pain and numbness, rigidity and sensitivity of the scar tissue, time to use the hands, and palmar pinch and grip strengths. The mean follow-up was 26.6 months in group 1, and 23.7 months in group 2. RESULTS: Complete disappearance of symptoms was obtained in 14 wrists (82.4%) in group 1, and in 15 wrists (88.2%) in group 2, with no significant difference between the two groups (p>0.05). Rigidity and sensitivity of the scar tissue were seen in nine wrists (52.9%) in group 1, and in two wrists (11.8%) in group 2 (p<0.05), which lasted 3.5 months and 1.5 months, respectively. In group 2, time to use the affected hand for basic needs (9 days) and normal function (21 days) was significantly shorter, compared to 18 days and 35 days in group 1, respectively (p<0.05). The mean differences of grip and pinch strengths of the two hands were -2.78 kg and -0.60 kg in group 1, and -0.77 and -0.46 kg in group 2, respectively (p>0.05). CONCLUSION: Although both methods of release yield satisfactory results in the mid- and long-term, mini skin incision performed on the distal side of the transverse carpal ligament is associated with less incision-related morbidity.

Elbow arthrolysis in severely stiff elbows.

INTRODUCTION: This study involves the results of open elbow arthrolysis performed on a series of patients having fixed joint contracture. PATIENTS AND METHODS: Eighteen patients were treated with open arthrolysis. Eleven patients had very severely stiff elbows (flexion arc less than 30 degrees ), five patients had severely stiff elbows (31 degrees -60 degrees ) and two patients had moderately stiff elbows (60 degrees -90 degrees ). Fixed flexion deformity was observed in nine patients preoperatively.The mean interval between the trauma and arthrolysis was 14.8 months. The mean age was 27 years. After radiological examination, lateral kocher incision was used on 13 patients, medial and lateral incision on 3 patients, transolecranon approach on 1 patient and anterior and posterior approach on 1 patient. External fixator was applied on four patients. Fasia lata interposition was performed in three patients. Additional procedures were as follows, bone fixation in five patients, bone grafting in two patients, nerve grafting in one patient, subcutaneous ulnar nerve transposition in three patients. The average follow-up time was 47 months. RESULTS: At the final evaluation, the mean extension deficit had improved from 55 degrees to 32 degrees . The mean end flexion increased from 81 degrees to 124 degrees postoperatively. The flexion arc of three patients in whom heterotopic ossification was excised had increased to 65 degrees . Infection was diagnosed in two patients (11%). CONCLUSION: The importance of this study is that the patients have fixed deformities and a long follow-up time. Severely stiff elbow is one of the main indications of open arthrolysis in the patients without muscle atrophy. We suggest sequential arthrolysis as an effective way to obtain good range of motion especially in severe stiff elbows as well as to maintain the ligamantous stability of the elbow joint.

[Isolated severance of the intrinsic motor branch of the ulnar nerve caused by stab injuries to the hand: A report of three cases]. / Uç olguda elde delici yaralanma sonucu olusan ulnar sinirin izole intrinsik motor dal kesisi.

Laceration of the deep intrinsic motor branch of the ulnar nerve below the Guyon canal is rarely seen in penetrating injuries of the hand. We report three patients (1 woman, 2 men) who underwent microsurgical repair for isolated injuries to the motor nerve branch of the ulnar nerve due to penetrating injuries to the hypothenar area of the hand. Two patients had normal sensation. All the patients had intrinsic muscle paralysis and claw deformity of some fingers, with significantly weakened grip and pinch strengths. Exploration showed isolated severance of the deep intrinsic motor branch of the ulnar nerve. One patient underwent end-to-end repair with epiperineural suture technique. Two patients required bridging with a sural nerve graft from the leg for 2-cm and 4-cm gaps, respectively, that occurred following nerve excision. During the follow-up period, grip and pinch strengths of all the patients approximated to the values of the normal side. Intrinsic muscle function and abduction and adduction of fingers recovered in two patients, whereas in one patient finger adduction was not reversible and claw deformity persisted in one finger even after two years.

[The frequency of vascular variations and complications with the use of the posterior interosseous artery flap]. / Posterior interosseöz arter flebi kullaniminda damarsal varyasyon ve komplikasyonlarin sikligi.

OBJECTIVES: We evaluated vascular problems in patients who were planned to receive posterior interosseous artery (PIA) flap for soft tissue defects in the dorsal hand, thumb, and the first web. METHODS: The study included 25 male patients (mean age 27 years; range 12 to 54 years) in whom reconstruction was planned with the use of the reverse PIA flap. The defects were in the following localizations: the dorsal hand (n=15), the first web (n=5), hypothenar region (n=3), and the palmar aspect of the wrist (n=2). The frequency of anatomic variations and complications were evaluated. RESULTS: The use of the PIA flap was cancelled in one patient (4%) due to an anatomic variation of the PIA in the forearm. The vascular pedicle of the flap was removed because of insufficient arterial perfusion due to the absence of distal carpal anastomosis and the donor tissue was used as a free flap in two patients (8.3%). The remaining 22 patients who received pedicled flaps were followed-up for a mean of 3.2 months (range 1.5 to 6.5 months), during which six patients (27.3%) developed venous insufficiency. A superficial vein anastomosis was performed in five patients within the first 24 hours, which resulted in complete improvement. One patient was not available for venous anastomosis and developed flap necrosis. The occurrence of venous insufficiency was not correlated with the timing of flap surgery, the size of the flap, and the placement of the flap pedicle (p>0.05). CONCLUSION: The use of the reverse PIA flap is appropriate for soft tissue defects in the dorsal hand, thumb, and the first web. However, the frequency of anatomic variations and vascular complications is higher compared to other reverse pedicled flaps.