Halil Bekler

A study of 60 patients with percutaneous trigger finger releases: clinical and ultrasonographic findings

We present the clinical results and ultrasonographic findings of 61 trigger digits treated with percutaneous A1 pulley release. An endoscopic carpal tunnel knife was used for the release in the outpatient department. The mean follow-up period was 3.5 months. A total of 55 digits (90%) had complete relief of their triggering postoperatively. Six digits (10%) had Grade 2 triggering clinically in the early postoperative period.The complications included six cases of insufficient release (10%), scar sensitivity in one patient, short-term hypoaesthesia in three digits (5%), and flexor tendon laceration noted on postoperative ultrasonography in eight digits (13%). No neurovascular damage was noted on the postoperative ultrasonography. Ultrasonograpy provides information about tendon laceration and changes in thickness of the pulleys and confirm A1 pulley release after surgery, but it does not alter clinical decision-making. We believe that pre- and postoperative ultrasonograpy does not need to be included as a routine examination.

Osteochondritis dissecans of the medial femoral condyle associated with malformation of the menisci.

Osteochondritis dissecans is a form of osteochondrosis limited to the articular epiphysis and the relationship of osteochondritis dissecans and discoid lateral meniscus has been clearly identified. This article presents a 10-year-old boy with osteochondritis dissecans of the medial femoral condyle associated with hypoplastic medial and partial deficient lateral menisci. The patient presented with activity-related pain and intermittent swellings of his left knee for 2 months without any evidence of significant knee trauma. Magnetic resonance imaging revealed anomalous medial meniscus mimicking displaced bucket-handle tear and partially deficient lateral meniscus with osteochondritis dissecans at the lateral aspect of medial femoral condyle without any significant bone loss with a non-dislocated fragment. Arthroscopy of the knee revealed an incomplete separated osteochondral flap with partial discontinuity that was unstable on probing on the lateral aspect of the medial femoral condyle. The medial meniscus was hypoplastic without a body and only the meniscal rim could be seen. The lateral meniscus had an anomalous vertical insertion of the posterior horn, normal body, but an absent anterior horn. The anterior cruciate ligament was intact, but looked like a peacocks tail. Arthroscopic fixation of the chondral lesion was performed. At 30-months follow-up, the boy had no limitation in his daily and sports activity. The present case is the first description of congenital anomaly of the both menisci and osteochondritis dissecans together. Meniscal or ligamentous anomalies of the knee may be associated with osteochondritis dissecans.

Paratricipital-triceps splitting "two-window" approach for distal humerus fractures.

Commonly, distal transcondylar and intra-articular distal humerus fractures are treated through a transolecranon approach. Other options for exposure, open reduction, and internal fixation exist to prevent the reported complications of olecranon osteotomy. The technique of triceps sparing access, as it has been reported before by others, allow adequate exposure in most of distal humerus fractures except for multifragmentary, mainly intra-articular types. We demonstrate the technique of the “two-window” approach, which combines a paratricipital posteromedial access with splitting the triceps lateral to the triceps tendon. Through a posteromedial incision, all surfaces of the distal humerus were accessed without muscle detachment from the olecranon. This approach does not compromise the ligamentous joint stability. In addition, the stabilizing effect of the anconeus muscle is not impaired because continuity with the lateral portion of the triceps is preserved, and denervation is avoided. It is extensile and provides adequate exposure of articular fracture comminution with the added advantage of the intact olecranon as a template for reduction. However, because the triceps is still in continuity it permits conversion to a transolecranon approach as necessary. The two-window approach is our preferred approach for all distal humerus fractures inclusively C3 fractures according to the ASIF/AO classification, except for complex volar shear fractures.

Effect of BMI on the clinical and radiological outcomes of pilon fractures

OBJECTIVE The aim of this study was to evaluate the effect of BMI on clinical and radiological outcomes of pilon fractures. We hypothesized that obese patients, defined as having a BMI of 30 or higher, would not have worse functional and radiological outcome compared to non-obese patients. METHODS This study retrospectively reviewed 42 patients (33 males and 9 females; mean age: 42.67±12.29 years, range: 18 to 67 years) who sustained tibial pilon fractures between January 2008 and May 2011. Each patients postoperative course, including the incidence of postoperative complications, and the length of hospital stay was determined from medical charts. At the final follow-up, clinical assessment was made according to the AOFAS score and radiological evaluation was made according to the Kellgren-Lawrence classification. RESULTS Twenty-nine patients had low-energy trauma, while 13 had high-energy trauma. Mean BMI was 28.96±4.86 kg/m2. There were 18 obese patients and 24 non-obese patients. Mean AOFAS score at the final follow-up was 68.36±20.71. The average follow-up time was 30.0±11.48 months. Superficial infection in the obese group occurred at a statistically significantly higher rate (p<0.05). Operation and hospitalization times occurred at a significantly higher rate in the obese group (p=0.001 and p= 0.041, respectively). CONCLUSION Body mass index does not affect the clinical and radiological outcomes of tibial pilon fractures, with the exception of superficial infection. Obese patients could be treated as non-obese patients with close monitoring of the wound.

Skin and subcutanous fat atrophy after corticosteroid injection for medial epicondylitis.

To the Editor: Medial and lateral epicondylitis are the most common elbow problems in adults. Corticosteroid injection for the treatment of medial epicondylitis is a frequently used method of conservative management. A 34-year-old right-handed woman was referred to our clinic with a 4-month history of pain along the medial side of her right elbow. She had been treated for medial epicondylitis with oral nonsteroidal anti-infl ammatory drugs, activity modifi cation, and local cold application for 1 month, and then had a 40 mg injection of methylprednisolone acetate to the right elbow for medial epicondylitis due to the resistance of pain. In 3 months’ time, her pain worsened. She could not wear short sleeves due to severe tenderness at the medial elbow, occurring even after contact with the torso. Examination revealed atrophy of the skin and subcutaneous fat over the medial epicondyle causing the epicondyle to become prominent like an osseous mass (Figure). Marked tenderness was observed over the prominent medial epicondyle by palpation. Intraoperatively, the atrophied skin and subcutaneous fat tissue were excised from an ellipsoid incision. Two chalky, whitish deposits of corticosteroid were observed over the fl exor aponeurosis. The deposits were excised. The common fl exor-pronator origin was partially detached by sharp dissection and refl ected without disturbing the medial collateral ligament. The underlying fi brous tissue was debrided. The medial epicondyle was drilled, creating multiple bleeding small holes, and then the fl exorpronator origin was reattached. The adjacent subcutaneous tissue and skin were released and brought over the epicondyle, forming good soft tissue coverage. Three years postoperatively, the patient had unlimited range of elbow motion with no epicondylar pain, and no pathologic bony prominence of the epicondyle was observed. Although steroid injection for the conservative treatment of medial epicondylitis is an alternative method, previously reported complications of periarticular injections and the case presented here demonstrate related adverse effects or complications. Injection into the medial site of the elbow may not be as innocent as expected if appropriate injection technique is disregarded. Tahsin Beyzadeoglu, MD Halil Bekler, MD Alper Gokce, MD Istanbul, Turkey doi: 10.3928/01477447-20110627-01

The use of an absorbable collagen cover (NeuraWrap) improves patency of interpositional vein grafts

OBJECTIVES Autologous interpositional vein grafts are used in peripheral arterial bypass procedures. Sudden exposure of vein grafts to arterial blood pressure is associated with increased wall tension leading to overdistension of the graft and changes in flow patterns. Overdistension of vein grafts often results in anastomotic leaks, thrombosis, and loss of patency. This study was designed to evaluate the use of a biodegradable collagen cover as a means of preventing overdistension of venous bypass grafts in a rat model. METHODS Twenty-two Sprague-Dawley female rats weighing 250-350 g were randomly assigned to two groups: study group (n= 15) and control group (n=7). In all the rats, a 10-mm segment of the left femoral vein was harvested and used as a graft in repair of a right femoral artery injury. Following this procedure, control rats remained untreated. After completion of the femoral artery repair in the study group, the graft was wrapped with a collagen cover of appropriate length (NeuraWrap Nerve Protector) and sutured to form a tube around the vein graft. At the end of the procedure, the intensity and duration of bleeding, and vessel patency were recorded and the proximal and distal arterial segments were examined by Doppler ultrasonography. All observations and measurements were repeated at 1 and 2 hours after surgery. After the second hour, all the rats were sacrificed and vein graft samples with the arterial portions were removed for histological study. RESULTS After removal of the vascular clamps of the control group, a sudden distension was observed in all the vein grafts. In this group, bleeding at the anastomosis site lasted for 1 to 3 minutes and was followed by ballooning of the grafts. In the study group, however, none of the samples exhibited distension and ballooning. There was no bleeding in 11 samples at all, and bleeding time was less than one minute in the remaining four samples. In the control group, only one graft was patent at two hours, one of the grafts was occluded after only three minutes. In the study group, all the grafts were patent and no thrombosis was noted. The mean blood flow velocity of the control group measured at 0 hour by Doppler ultrasonography was 0.93+/-0.33 cm/sec in the proximal artery, and 0.73+/-0.44 cm/sec in the distal artery. The mean blood flow velocities in the proximal and distal arteries of the study group were as follows, respectively: at 0 hour: 0.45+/-0.27 and 0.46+/-0.22 cm/sec; at 1 hour: 0.40+/-0.22 and 0.62+/-0.40 cm/sec; and at 2 hours: 0.55+/-0.22 and 0.64+/-0.37 cm/sec. CONCLUSION Prevention of overdistension of vein grafts with the use of an external cover decreases anastomotic leaks, protects the intimal media, maintains blood flow, reduces the incidence of thrombosis, and thus provides a higher patency rate.

Aseptic drainage associated with polyglactine sutures used for repair of Achilles tendon ruptures

The aim of surgical treatment of Achilles tendon ruptures is to restore stability of the tendon. Various suture techniques and materials can be used for this purpose. Suture materials may be polyfilament or monofilament, absorbable or nonabsorbable. We presented four patients who developed severe chronic discharges associated with thick polyglactine (Vicryl) used during open repair of acute Achilles tendon ruptures. Surgical removal of suture materials and debridement resulted in complete improvement without any complications. The use of thick suture materials and large knots should be avoided in the repair of Achilles tendon ruptures. Polyfilament and absorbable sutures may pose problems due to their tendency to cause bacterial colonization and tissue rejection.

The contribution of locked screw-plate fixation with varying angle configurations to stability of osteoporotic fractures: an experimental study

OBJECTIVES This experimental study was designed to find new ways of improving stabilization of fractures in osteoporotic elderly patients through alterations made in the configuration and geometry of locked screw-plate fixation used in the conventional plate technique. METHODS Four screw configurations with varying angulations were used for plate-bone construction. Forty iron plates of high quality (100x35x3 mm) were divided into four groups and two screw holes, 3 mm in diameter, were drilled on each plate at a distance of 15 mm. In group A, the holes were drilled so that the screws would be vertically sent to the bone interface. In the remaining groups, the holes were drilled for convergent (group B, 15 degrees ) and divergent (group C, 15 degrees ; group D, 30 degrees ) screw orientation. Screw-plate fixation was tested in a modified osteoporotic bone (Osteoporotic Generic Bone, Synbone) on an Instron materials testing system with an axial pullout force of 0.1 mm/sec. Failure loads were read from load-displacement curves and the type of failure was noted. RESULTS Screws placed in divergent orientations showed the highest axial pull-out strength (group C, 83.3 N/mm; group D, 80.8 N/mm), followed by convergent placement (72 N/mm) and vertical placement (66.7 N/mm). The type of failure was breakage of the bone sample in divergent configurations, and screw pull-out in convergent and vertical configurations. CONCLUSION Divergent constructs may be a promising alternative to conventional screw placement in treating osteoporotic fractures.

The Proposal and Early Results of Capitate Forage as a New Treatment Method for Kienbock's Disease.

Kienböcks disease is a type of avascular necrosis which disrupts the biomechanics of the wrist as a result of the changes it creates in the lunate bone. Its treatment generally consists of osteotomies intended to relieve the pressure on the bone, pedicle bone grafting applications aiming to increase bone blood supply, and salvage procedures. Capitate forage is a safe and simple-to-apply surgical treatment method which is intended to enhance neovascularization of the lunate much like a radius osteotomy or core decompression

Similar effectiveness of the open versus endoscopic technique for carpal tunnel syndrome: a prospective randomized trial

This prospective randomized study aims at evaluating the electrophysiological results of endoscopic and open carpal ligament release in patients with carpal tunnel syndrome. Included in the study were 41 patients diagnosed with carpal tunnel syndrome (21 hands in the endoscopic group and 20 hands in the open group). The Boston questionnaire was administered preoperatively and postoperatively to the patients, and their functional capacities and symptom severities were recorded. Physical examination was carried out preoperatively and in the postoperative sixth month. Demographic data and preoperative Boston symptomatic and functional scores were similar between both groups. A significant improvement was obtained in the Boston symptomatic and functional scores of both groups, but no significant difference was found between the groups in terms of improvement in the symptomatic and the functional scores. A significant shortening in median nerve motor distal latency and an increase in the velocity of sensory conductions were determined in both groups in the postoperative electromyography, but no difference was found between them in terms of improvement in the electromyography values. It was shown both clinically and electrophysiologically that endoscopic carpal tunnel surgery was as effective as open surgery as a treatment method for carpal tunnel syndrome.