Use of Generalizability Theory Evaluating Comparative Reliability of the Scapholunate Interval Measurement With X-ray, CT, and US.

RATIONALE AND OBJECTIVES: There is no universally accepted standard technique for measuring the scapholunate interval and no specific sources of measurement error have been identified. We aimed to establish a set of normal radiological criteria for the scapholunate interval that could be used in comparative studies of wrist pathology to determine interobserver reliability and to identify potential errors that might influence measurements. MATERIALS AND METHODS: A total of 60 healthy volunteers participated in the study. Scapholunate interval was measured by three independent observers using X-ray, CT, and US in four positions, including neutral, fist, radial and ulnar deviation. Inter-observer reliability was tested using intraclass correlation coefficient. Generalizability theory was applied to evaluate specific sources of measurement error related to participant, observer, imaging modality and measurement position. RESULTS: In neutral position, the scapholunate interval measured by X-ray, CT, and US was 3.1 mm, 3.5 mm and 3.5 mm respectively. The interval remained constant during fist and radial deviation but decreased during ulnar deviation. Correlation coefficients ranged from 0.874 to 0.907 for X-ray, 0.773-0.881 for CT and 0.964-0.979 for US. In the generalizability study, the participant x modality x position interaction accounted for the largest proportion of total variance (29%). CONCLUSION: X-ray, CT, and US are reliable modalities for measuring the scapholunate interval, with US having the highest reliability. Participant and position factors may independently contribute to measurement error. Therefore, standardized measurement positions are recommended to obtain reliable measurement results.

Prediction of disability in trigger finger: a cross-sectional and longitudinal study.

The aim of this prospective study of 55 patients was to analyse the cross-sectional and longitudinal relationship between disability and physical and psychological variables after conservative treatment of trigger finger and to determine the predictive factors for the post-treatment disability score and change in disability score. The primary outcome measure was the Disabilities of the Arm, Shoulder, and Hand questionnaire. Potential predictive factors included pain, number of triggering events, depression, anxiety and kinesiophobia. Disability correlated strongly with anxiety, moderately with pain and depression and weakly with triggering and kinesiophobia. The change in depression score correlated significantly with the change in disability score. Post-treatment pain and anxiety scores accounted for 47% of the explained variance in disability score. Improvement in depression after treatment accounted for 18% of the explained variance in disability change score. Psychological variables appear to be potential predictors of disability.Level of evidence: IV.

Responsiveness and Validity of Weight-Bearing Test for Measuring Loading Capacity in Patients With Triangular Fibrocartilage Complex Injury.

CONTEXT: Weight-bearing test (WBT) is a noninvasive quantitative test which has been used recently to determine loading capability of the individuals. The aim of this study was to strengthen the evidence for using the WBT test for measuring weight-bearing capacity of the upper-extremity with the specific objective of examining the internal and external responsiveness and concurrent validity of the test in patients with triangular fibrocartilage complex injury. DESIGN: Single-group repeated measures. METHODS: Internal responsiveness was assessed using effect size statistics. The correlation coefficient was used to examine external responsiveness by testing 5 hypotheses regarding predefined correlations between the changes in the measurements. Concurrent validity was evaluated by analyzing correlations between the WBT and other measurements. Thirty-one patients with triangular fibrocartilage complex injury were included for the analysis of the concurrent validity. Eighteen patients who completed all measurements at baseline and at 3-month follow-up enrolled for the responsiveness analysis. Measurements included the WBT, pain intensity, grip strength, and upper extremity functional level. RESULTS: The WBT test was able to detect statistically significant changes in weight-bearing capacity between baseline and follow-up (P = .0001). The effect size of the WBT was large. Three out of 5 hypotheses (60%) were confirmed, a good correlation was found between changes scores of the WBT and grip strength (r = .478; P < .05). There were significant correlations between the WBT and other measurements (r value range from -.401 to .742; P < .05). A higher correlation was found between the WBT and grip strength (r = .742; P = .0001). CONCLUSIONS: The responsiveness and concurrent validity of the WBT test confirmed that it is able to measure change in weight-bearing capacity in patients with triangular fibrocartilage complex injury.

Persistent infection of Mycobacterium tuberculosis in a patient with Behçet's disease after rotator cuff repair surgery: A case report.

Tuberculosis (TB) infection is a common health problem in low socioeconomic populations in developing countries. Osteoarticular TB is a disease that rarely occurs outside the vertebral column and is often diagnosed late or misdiagnosed, particularly in non-weight bearing joints. A 51-year-old female patient with Behçet's disease presented with shoulder TB following rotator cuff repair surgery, leading to joint resection as a result of recurrent infections with no reproduction in culture samples due to delayed diagnosis. Surgical excision was proposed for the treatment of draining a mass with a sinus tract opening into the joint on the anterior aspect of the right shoulder. A diagnosis was able to be reached after 13 operations, based on the presence of TB bacilli in the pathological examination of the samples. In conclusion, TB should be considered in the absence of reproduction in culture samples taken during persistent post-surgical infections.

Is simple decompression enough for the treatment of idiopathic cubital tunnel syndrome: A prospective comparative study analyzing the outcomes of simple decompression versus partial medial epicondylectomy.

OBJECTIVES: This study aims to compare the clinical and functional outcomes of simple in-situ decompression and partial medial epicondylectomy for the treatment of idiopathic cubital tunnel syndrome (CuTS). PATIENTS AND METHODS: Between March 2014 and December 2016, 71 patients (31 males, 40 females; mean age 46.7 years; range, 38 to 62 years) with CuTS scheduled to undergo simple in-situ decompression (group 1) or partial medial epicondylectomy (group 2) were prospectively reviewed. All patients were analyzed with clinical examination (Tinel sign, Froment's and Wartenberg's signs, elbow flexion test, subluxation), and McGowan scores before and after surgery. Final outcomes were reviewed with Wilson and Krout grading system. RESULTS: There was no significant difference between the study groups in regard to Wilson and Krout grading and McGowan scores postoperatively. Group 1 had significantly better grip and key pinch strength values compared to group 2 at the final follow-up control. CONCLUSION: In-situ decompression and partial medial epicondylectomy represent efficient and safe methods for the treatment of idiopathic CuTS. When their efficiency is compared, in-situ decompression had better grip and key pinch strength values and more excellent outcomes compared to partial medial epicondylectomy.

Primary extracranial meningioma of the lower limb.

This paper is about a primary extracranial meningioma case of a 40-year-old male patient who presented with a complaint of a rapidly growing painless stiff mass located in his left thigh. The magnetic resonance imaging examination revealed that the lesion was well-circumscribed and with isosignal intensity to muscle on T1-weighted images and with a relatively hiperintense on T2-weighted images. The histopathological analysis of the specimens both from the incisional biopsy and the excisional surgery were typical of meningioma showing spindle cell proliferation with a whirling pattern. Although extracranial meningiomas are very rare, it should be considered in the differential diagnosis of a spindle cell neoplasm.

Prevention of web creep using a new frame after synpolydactyly surgery.

The main goal in syndactyly surgery is to create a normal web space; however, it is difficult to achieve the best clinical results in older and complex cases with bony fusions and joint deformities requiring osteotomies. In these complex cases, proper postoperative wound care is difficult to achieve due to the web contractures and deformities. In our report, we introduce a new technique using a frame that we called the "Hittite Sun," which helps in proper wound management to reduce wound healing problems that lead to web creep. Between 2002 and 2006, this frame was used in operations for 46 webs, and the results were compared with those of 30 operated webs in which conventional wound management technique was used. It was found that significantly lower complication rate and lesser web creep formation was seen in these patients, which were managed using the frame, compared with the cases with conventional wound care. The frame was found to be effective for prevention of severe web creep especially in complex synpolydactyly surgery.

Talonavicular joint approach to the talar body: a cadaver study.

BACKGROUND: Lesions of the talar dome or tumors within the talar body may require an open approach with medial or lateral malleolar osteotomies. The aim of this study was to evaluate the possibility and feasibility of a new minimally invasive approach without osteotomy, using the talonavicular joint (TJ) as the entry portal for lesions of the talar body. MATERIALS AND METHODS: Nine cadaveric feet were used for this study. Using the TJ and a 5-mm skin incision we aimed to reach the superolateral, superomedial, inferolateral and inferomedial corners of the talar body under fluoroscopy. A 2-mm Kirshner wire and a 4-mm cannulated drill bit were used to reach the desired target area and an angled curette was used for curettage after reaching the target. The proximity of vascular structures to the entry portal was noted. The talar and navicular joint surfaces were checked for any damage. The articular areas of the talar heads and the defect areas were measured. RESULTS: All 4 targets and even the posterior talus could be reached by this approach. The nearest neurovascular structures were the saphenous vein and the saphenous nerve. The navicular cartilage was not damaged in any specimen. The talar defect area corresponded to only 3.3% of the talar head cartilaginous area. CONCLUSION: The TJ approach can be used to reach lesions in all regions of the talar body without the need for an osteotomy. A mini-incision may be used to retract the saphenous nerve and vein. Damage to the talar head cartilage is minimal with this approach which requires no special equipments. CLINICAL RELEVANCE: This study shows that talar dome lesions can be reached with a minimally invasive method.

Association of hypospadias with hypoplastic synpolydactyly and role of HOXD13 gene mutations.

OBJECTIVES: To present the association of hypospadias with hypoplastic synpolydactyly and discuss the molecular genetic basis of these conditions. METHODS: A large synpolydactyly kindred first described in 1995 was reinvestigated. Affected and unaffected subjects were interviewed, and pedigrees of the most recent generations were constructed. The marriages of two affected individuals were identified. The siblings who were homozygous for the deformity were asked to attend our institution and underwent a detailed clinical evaluation. Genetic studies and mutation screening were performed using polymerase chain reaction on genomic DNA extracted from venous blood. RESULTS: Of the 245 members of the kindred, 125 individuals were affected. Of these 125 individuals, 12 were homozygotes (6 females and 6 males) with a mean age of 12 years. The remaining 113 individuals (57 females and 56 males) were heterozygotes showing milder limb deformities. No sex-related phenotypic difference was found in the extremity findings, but all the males with a homozygote pattern had hypospadias. Three had distal penile, two had mid-shaft, and one had penoscrotal hypospadias. Of the affected 56 heterozygote males, 22 were also noted to have distal hypospadias in various forms. Neither the heterozygote nor the homozygote females had any genital anomalies. The laboratory tests and karyotype profiles of these individuals were normal. Mutation screening of the homozygote subjects revealed a polyalanine duplication band of nine additional alanine residues at the human HOXD13 gene. CONCLUSIONS: These findings strongly suggest that specific mutations in HOXD13 gene may cause both hypoplastic synpolydactyly and hypospadias.

Use of a splint following open carpal tunnel release: a comparative study.

This study was undertaken to compare the clinical effectiveness and costs of postoperative splintage and late rehabilitation with a bulky bandage dressing versus early rehabilitation after carpal tunnel release. In this comparative study, 46 patients were randomly divided into 2 groups. In each group, 3 patients were excluded because of improper follow-up, leaving a total of 40 patients. Group 1 used a splint (exercises given 3 wk postoperatively) and group 2 was given a bulky bandage (exercises provided immediately) after open release. Patients were assessed preoperatively and at the first and third postoperative months with the Questionnaire of Levine for Clinical Assessment of Carpal Tunnel Syndrome. The 2 groups were similar in terms of preoperative functional status scores and in controls at the first and third months (P=.549, P=.326, P=.190). When both groups were compared, no statistical significance was found regarding symptom severity scale scores preoperatively and at the first postoperative month (P=.632 vs P=.353). At the third month, scores were lower in favor of group 2 (P=.023). Additionally, 16 of 20 patients (80%) in group 1 reported a heavy feeling and discomfort caused by the splint. This problem was not reported by the patients in group 2. The cheapest splint on the market was 9 times more expensive than a bulky dressing. The investigators concluded that postoperative immobilization with a splint has no detectable benefits. Use of bulky dressings and abandonment of the use of postoperative splints may prevent unnecessary expenditures without sacrificing patient comfort or compromising the course of healing in carpal tunnel surgery.

Synpolydactyly of the foot in homozygotes.

In 2002, we reinvestigated a large synpolydactyly kindred first described in 1995. It was found to have expanded with an increase in number of homozygous offspring. These homozygotes had severe hypoplasia, with synpolydactyly of their hands and feet. We present the clinical, genetic, and surgical findings of this deformity and the histologic findings of the removed bones of the heterozygous and homozygous members. There were 125 affected individuals (113 heterozygotes and 12 homozygotes) of 245 members of the past five generations. We identified seven marriages in which both spouses were affected. Twelve offspring from these marriages had homozygote genetic patterns, hypoplastic synpolydactyly of the hands, and a distinctive foot deformity, with a prominent great toe and syndactylized hypoplastic minor toes. From clinical and surgical perspectives, their hand and foot deformities were different from those of their parents. We surgically treated both feet of four individuals with this deformity, which we called "homozygote foot synpolydactyly." Clinically, the deformity consisted of a supinated prominent great toe, hypoplastic and severely synpolydactylized minor toes, and secondary problems. Radiographically, the bones were underdeveloped, unshaped, and largely fused. Abundant cartilage covering the bones was observed surgically and histologically. Genetically, analysis of HOXD13 identified a 27-base pair duplication with a homozygote pattern. The foot deformity of the homozygotes was so distinctive and complicated that it should be considered a separate foot synpolydactyly type--homozygote foot synpolydactyly.

[Relationship between the mechanical and anatomic axis and orientation angles of the knee joint and functional capacity of patients with osteoarthritis]. / Osteoartritli hastalarda diz ekleminin mekanik ve anatomik akslarinin ve yönelim açilarinin fonksiyonel kapasiteyle iliskisi.

OBJECTIVES: We investigated the relationship between the mechanical-anatomic axes and angles of the knee joint and functional levels of patients with primary osteoarthritis. METHODS: A total of 35 patients (27 females, 8 males; mean age 58+/-9 years; range 42 to 77 years) with knee osteoarthritis were included. After physical examination, weight-bearing anteroposterior x-rays of the knees were obtained, on which measurements of the following were made: mechanical axis deviation (MAD), medial proximal tibial angle (MPTA), anatomic tibiofemoral angle (aTFA), mechanical lateral distal femoral angle (mLDFA), and joint line congruence angle (JLCA). Pain was evaluated by both the Western Ontario McMaster Osteoarthritis Index (WOMAC) and a visual analog scale (VAS). Functional capacity was assessed using the physical function and global indices of WOMAC. RESULTS: There was a moderate correlation between body mass index and the WOMAC global index (r=0.47, p<0.05). Radiographic evaluations revealed varus deformity in 28 patients. There was a correlation between aTFA and the physical function (r=0.47) and global (r=0.41) indices of WOMAC (p<0.05). Functional capacity and pain were not correlated with the other mechanical angles of the knee joint (p>0.05). CONCLUSION: In view of our results, aTFA may be considered one important criterion in designing treatment and planning surgery for patients with primary osteoarthritis.

Augmentation vs Nonaugmentation Techniques for Open Repairs of Achilles Tendon Ruptures with Early Functional Treatment: A Prospective Randomized Study.

A prospective randomized study was conducted in order to compare augmentation technique versus nonaugmentation technique, followed by early functional postoperative treatment, for operative repair of Achilles tendon ruptures. Twenty-four consecutive patients were assigned to two groups. Group I included 12 patients treated with Lindholm augmentation technique, whereas group II included 12 patients treated with modified Kessler end-to-end repair. Thereafter, these patients had postoperative management with a below-knee-cast for three weeks. The physioteraphy was initiated immediately after the cast was removed. Full weight bearing was allowed after five weeks postoperatively in the both groups. Two patients had reruptures in group II, whereas group I had prolonged operative time significantly. The patients with reruptures underwent reoperations and at the most final follow-up, it was observed that they could not resume to sporting activities. The other objective and subjective results were similar between two groups. Because of quite high rerupture rate in the group of patients treated with nonaugmentation technique, we favor functional postoperative treatment with early ankle movement in the patients treated with augmentation technique for the management of acute rupture of the Achilles tendon. Key PointsA prospective randomized study was conducted in order to compare augmentation technique versus nonaugmentation technique, followed by early functional postoperative treatment, for operative repair of Achilles tendon ruptures.Group I included 12 patients treated with Lindholm augmentation technique, whereas group II included 12 patients treated with modified Kessler end-to-end repair.Functional postoperative treatment with early ankle movement in the patients treated with augmentation for the management of acute rupture of the Achilles tendon is recommended.

Posterior fixation of thoracolumbar burst fracture: short-segment pedicle fixation versus long-segment instrumentation.

OBJECTIVE: The treatment of thoracolumbar burst fracture is a controversial issue. Short-segment (SS) pedicle fixation has become a popular treatment option. However, there are several studies regarding the high rate of failure. The aim of this prospective study was to compare SS versus long-segment (LS) instrumentation. METHODS: For this purpose, 18 consecutive patients were assigned to two groups. Group 1 included nine patients treated by SS pedicle fixation, whereas group 2 included nine patients treated by LS instrumentation. SS instrumentation was pedicle fixation one level above and below the fractured vertebra. LS instrumentation was hook fixation (claw hooks attached to second upper vertebra and infralaminar hooks attached to first upper vertebra) above and pedicle fixation (pedicle screws attached to first and second lower vertebrae) below the fractured vertebra. RESULTS: As a result, measurements of local kyphosis, sagittal index, and anterior vertebral height compression showed that the LS group had a better outcome at final follow-up (P < 0.05). Also, the SS group had a 55% failure rate, whereas the LS group had prolonged operative time and increased blood loss. However, there was no difference between the two groups according to Low Back Outcome Score. CONCLUSIONS: In conclusion, radiographic parameters demonstrated that LS instrumentation is a more effective management of thoracolumbar burst fractures. Nevertheless, clinical outcome was the same between the two groups. However, our conclusions were based on posterior-only surgery. Anterior column support would negate the need for LS fixation. Also, SS would have been more successful if two above and two below pedicle screws were used.

[Familial glomus tumor encountered in the same finger and localization in four family members]. / Ailenin dört üyesinde ayni parmak ve yerlesimde görülen glomus tümörü.

A 35-year-old man was referred to our clinic by a neurosurgeon for hypersensitivity and severe pain in his right middle finger. History showed that the symptoms had been present for three years and he had made several attempts to seek medical attention. A sensitive, very painful mass was palpated under the eponychium of his right middle finger. The tumor was surgically removed and histological examination confirmed the clinical diagnosis of a glomus tumor. Inquiry into the family history revealed that the same problem existed in the same localization with similar complaints in the father and two daughters. Both the records of the father's operation 10 years before and clinical-radiological findings of the daughters were consistent with a familial entity. In the presence of hypersensitivity and pain in the finger, family members should be inquired and a diagnosis of familial glomus tumor should be considered.

Radiographic evaluation and unusual bone formations in different genetic patterns in synpolydactyly.

OBJECTIVE: To compare the radiological findings of heterozygous and homozygous subjects with synpolydactyly (SPD) and to discuss their unusual bone formations. DESIGN AND PATIENTS: Families with hand and foot SPD were examined. Genetic analysis was performed with blood samples and the pedigree was constructed. The affected individuals, especially those with distinctive phenotypic features, were invited to our orthopaedics clinic for further diagnostic studies. All participants underwent detailed clinical and X-ray examinations. RESULTS: Of the invited patients, 16 (five female and 11 male; age range 4-37 years, mean age 10.75 years) were included in our study, and hand and foot radiographs were obtained. All subjects had bilateral hand radiographs (32 hands), and 14 had bilateral foot radiographs (28 feet). Genetic analysis revealed 12 heterozygote (75%) and four (25%) homozygote phenotypes. Among patients enrolled into the study nine (three homozygotes, six heterozygotes) had SPD of both hands and feet bilaterally (tetrasynpolydactyly). Six unusual bone formations were observed in the hands and feet: delta phalanx, delta metacarpal/metatarsal, kissing delta phalanx, true double epiphysis, pseudoepiphysis and cone-shaped epiphysis. There were major differences in radiological and clinical manifestations of homozygote and heterozygote phenotypes. The homozygous SPD presented with very distinctive unusual bone formations. CONCLUSION: The existence and variety of unusual bones may indicate the severity of penetrance and expressivity of SPD.

Epithelioid sarcoma-like hemangioendothelioma: a case report.

Seven cases of an unusual low-grade vascular tumor were reported in a recent study. Despite its similarity to epithelioid sarcoma, this tumor was termed epithelioid sarcoma-like hemangioendothelioma because of the subtle histopathological and immunohistochemical differences. Another case of this rare entity in a 70-year-old woman who suffered from a painful mass on the anterior aspect of the right cubital fossa is presented here, together with a review of the relevant literature.

Hypoplastic synpolydactyly as a new clinical subgroup of synpolydactyly.

A large kindred which was first described in 1995 was investigated again. We present the clinical, radiological, genetic and surgical findings of the hand deformities found in homozygote individuals which we called "hypoplastic synpolydactyly". There were 125 affected (heterozygote or homozygote) people out of 245 subjects in the five last generations. We identified seven marriages of two affected people. Twelve offsprings, of these marriages had a homozygote genetic pattern and "hypoplastic synpolydactyly". From both the clinical and surgical perspectives, their hand deformity was distinctive from that of their parents. We surgically treated both hands of three individuals with this deformity. The hand deformity of these homozygotes was so complicated and distinctive that it can be evaluated as a new subgroup of synpolydactyly.