Fatih Kabakas

Treatment of nonunions of the distal phalanx with olecranon bone graft

Distal phalangeal fractures are the most common fractures of the hand but nonunions are unusual in the distal phalanx. Eleven patients were operated on for nonunions of the distal phalanx. The diagnosis of nonunion was made by the presence of the clinical (pain, deformity, instability) and radiological signs of nonunion more than 4 months after the initial injury. Three patients had developed infection and four of them had bone resorption after their initial treatments, which probably caused nonunion. Olecranon bone grafting combined with Kirschner wire fixation was done in all patients. The mean follow up was 7 months (range 5–18 months). There were no major complications at the donor or recipient sites. One patient had a haematoma formation at the donor site. There was complete radiological union of bone-grafted sites in all patients except one. There were no cases of pain, deformity, or instability after the treatment. The olecranon bone graft was found to be safe and easy to harvest. Its strong tubular structure replaced the distal phalanx successfully.

Olecranon bone graft: revisited.

Autogenous bone grafts are frequently in use in the field of reconstructive upper extremity surgery. Cancellous bone grafts are applied to traumatic osseous defects, nonunions, defects after the resection of benign bone tumors, arthrodesis, and osteotomy procedures. Cancellous bone grafts do not only have benefits such as rapid revascularization, but they also have mechanical advantages. Despite the proximity to the primary surgical field, cancellous olecranon grafts have not gained the popularity they deserve in the field of reconstructive hand surgery. In this study, the properties, advantages, and technical details of harvesting cancellous olecranon grafts are discussed.

Successful replantation of an amputated nose after occupational injury.

To the Editor: The nose is one of the critical aesthetic subunits of the face. Partial or total tissue loss results in major aesthetic consequences. These aesthetic problems and concerns are the main reasons why nasal reconstruction dates back so many years. Introduced first in India, nasal reconstruction has been performed since 600 BC. Total amputation of the tip of the nose was observed in a 34year-old man who presented to the emergency services as a result of occupational injury (Fig. 1). An artery running perpendicularly between the inferior lateral cartilages, possibly a branch of the anterior ethmoidal artery and a vein at the level of the columella, was identified. Vascular anastomoses were carried out using 10-0 nylon sutures. The patient stayed in the hospital for 10 days, during when skin coloration and circulation was normal (Fig. 2). Reattachment of the amputated nose in the way of composite grafts has been performed for some 500 years. The first documented successful nonvascular nose replantation was performed by Fioravanti in 1570. In 1836, Hoffacker reported the first large series of cases. Hoffacker attached the amputated segment as composite grafts in 16 cases, 12 of which were successful nonvascular replantations. In general, badly traumatized piece and calibration of small vessels comprise serious challenges of vascular replantation of the nose. Nasal replantation with microvascular techniques is rare owing to technical difficulties. Experience is derived mainly from isolated clinical reports owing to the absence of a large series. These cases are usually amputations as a result of animal (primarily dogs) and, rarely, human bites. In the present case, amputation occurred as a consequence of occupational accident. The biggest challenge in nose replantations is related to the problems with the recipient vessel. In the meantime, low oxygen requirement of the cartilages can be an advantage in nose and ear amputations. Should primary venous repair cannot be accomplished, venous insufficiency can be remedied with various techniques including the arteriovenous fistula (if 2 arteries can be found), pinpricks, medical leech treatment, and heparinized abrasions. However, arterial anastomosis is an absolute requisite for microvascular replantation. James, in the first nose replantation involving the upper lip segment, used the labial vessels as recipient vessel. Besides the labial artery, the left nasal branch of the facial artery, the right nasal branch of the left supratrochlear artery, a branch of the angular or lateral nasal artery, and the dorsal nasal artery have been used as recipient arteries in other replantation cases. All these arteries are the external arteries of the nose. In the present case, the recipient artery was a branch of the anterior ethmoidal artery, an internal artery of the nose, running perpendicularly in the intercartilaginous region. Replantation after partial or total amputation of the nose yields a surgical outcome that is closest to the normal anatomy. Near-perfect outcome in aesthetics and functionality can be

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.

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.

Intramedullary Venous Drainage System for Distal Fingertip Replantations

Abstract The number of venous anastomoses performed during fingertip replantation is one of the most important factors affecting the success of replantation. However, because vessel diameters decrease in the zone 1 level, vessel anastomoses, especially vein anastomoses, are technically difficult and, thus, cannot be performed in most cases. Alternative venous drainage methods are crucial when any reliable vein repair is not possible. In the literature, so many artery-only replantation techniques have been defined, such as arteriovenous anastomoses, forming an arteriovenous or venocutaneous fistula, manual milking and massage, puncturing, and external bleeding via a fishmouth incision and using a medical leech. It has been shown that, in distal fingertip replantations, the medullary cavity may also be a good way for venous return. In this study, we introduce an alternative intramedullary venous drainage system we developed to facilitate venous drainage in artery-only fingertip replantations. The results of 24 fingertip replantations distal to the nail fold by using this system are presented with a literature review.

Plate fixation in the treatment of complex forearm open fractures

Objectives: We aimed to evaluate the safety and outcomes of plate-screw fixation used for the immediate treatment of type-IIIC open fractures of forearm bones with complex soft tissue injuries. Methods: A total of 22 patients (mean age: 31.6, range: 24-60) treated between 2004-2010 were retrospectively analyzed. All injuries resulted from high-energy traumas and fractures were classified using AO classification. All patients had vascular and nerve injuries, and four had skin defects associated with double fractures of the forearm. All patients were operated on within the first eight hours following injury. Six patients with comminuted fractures or with bone defects underwent primary bone grafting, and one patient was treated with shortening. Primary skin closure was achieved in 17 patients and three patients underwent immediate repair using skin grafts, while two patients were repaired with immediate transposition flaps. Bony unions, complications, and functional results via a DASH questionnaire were investigated. Results: Mean follow-up was 28 months (range: 14-70). In all patients, radius bone union was achieved. Two patients underwent a Sauve-Kapandji procedure, utilizing the fractured segment of the ulnar diaphysis as a graft for radius. In one patient, osteosynthesis was repeated after 6 months because of nonunion. Mean period to bony union was 4.59 months (range: 3-6). Superficial infection developed in three patients after the operation, and was resolved with antibiotic therapy. The mean DASH score after surgery was 25.6. Conclusion: In high nergy traumas of the upper extremity associated with complex injuries and Type-IIIC forearm fractures, severity of soft tissue injuries determined the functional results in patients, demonstrating it is possible to achieve a safe and efficient fixation with immediate plate-screw osteosynthesis.

Tissue forceps for stabilizing amputated parts in a finger replantation

Tremor of the assistant while holding the amputated finger during preparation for replantation is a problem. Few methods are found in literature to stabilize the amputated part. Reported here is the usage of tissue forceps for stabilizing the amputated part while the surgeon is tagging the nerves and vessels under a microscope.

The function and the strength of the thumb is not affected when the extensor pollicis longus tendon is left out of the extensor retinaculum

Purpose: Leaving extensor pollicis longus (EPL) tendon out of the retinaculum in cases performed through a dorsal approach at the level of the extensor retinaculum after opening the 3rd extensor compartment reduces risk of adhesion and rupture. The aim of this study was to attempt to understand whether leaving EPL in the subcutaneous tissue that is released from the extensor compartment during surgery, without reconstructing the third extensor compartment, causes any change to extension strength and range of motion (ROM) of the interphalangeal (IP) and metacarpophalangeal (MCP) joints of the thumb. Patients and methods: 20 patients operated on between 1995 and 2013 were evaluated retrospectively. The EPL tendons of all patients were left out of the extensor retinaculum after opening the 3rd extensor compartment through a dorsal approach to wrist. The following surgeries were performed: wrist arthrodesis in four patients, vascularized bone flaps from the 4th ECA (extensor compartmental artery) for KienbA¶ck’s disease in two patients, open reduction after perilunate fracture-dislocations in two patients, proximal row carpectomy after KienbA¶ck’s disease in two patients, and distal radius fracture surgery through a dorsal approach in six patients. Extension strength (in kg) and voluntary ROM (in degree) of the MCP and IP joints of the thumb were measured. Opposite extremity values were assessed and compared statistically. Results: No statistically significant reduction was determined in strength and ROM of IP and MCP joints of the thumb on the operated side of patients whose EPLs were left out of the retinaculum compared with the non-operated side. Conclusion: It was determined that leaving the EPL tendon out of the retinaculum in cases with increased risk of adhesions and rupture did not cause marked muscle weakness or loss of range of movement.

Flexor Tenosynovitis Due to Tuberculosis in Hand and Wrist: Is Tenosynovectomy Imperative?

AbstractThe treatment of flexor tenosynovitis in the hand and wrist due to tuberculosis is controversial. Although some authors recommend the antituberculous chemotherapy, the others recommend the surgical treatment. In this article, 12 patients with synovial tuberculosis of the flexor aspect of the hand and the wrist were evaluated with respect to diagnosis and treatment modalities. None of the patients had a history of tuberculosis, concomitant disease, immunosuppressive drug use, drug abuse, and human immunodefficiency virus positivity. A chest x-ray and family screening were performed in all of the cases, none had evidence of tuberculosis in the lung. The biopsy, histopathological examination, acid-fast bacillus staining, and BACTEC tuberculosis culture were performed. Antituberculous chemotherapy was initiated in patients diagnosed with tuberculosis by either histological or microbiological examinations. The patients did not undergo any further surgery after biopsy procedures. The lesions regressed totally in all patients after 3 months of treatment. Carpal tunnel syndrome symptoms and signs recruited at five months of treatment. In patients with flexor tuberculosis tenosynovitis, it is possible to achieve good results by applying only medical therapy after a biopsy, and without the need for further surgery.