Haluk Ozcanli

Definition of a safe-zone in open carpal tunnel surgery: a cadaver study

Carpal tunnel decompression is one of the most common surgical procedures in hand surgery. Cutaneous innervation of the palm by median and ulnar nerves was evaluated to find a suitable incision preserving cutaneous nerves. A morphometric study was designed to define the safe-zone for mini-open carpal tunnel release. Sixteen fresh-frozen (8 right, 8 left) and 14 formalin-fixed (8 right, 6 left) cadaveric hands were dissected. Anatomy of the palmar cutaneous branch of the median and the ulnar nerve, motor branch of the median nerve, superficial palmar arch were evaluated relative to the surgical incision. We also identified the motor branch of the median nerve. Detailed measurements of the whole palmar region are reported in this study. The motor branch of the median nerve was extraligamentous as 60%, subligamentous as 34%, transligamentous as 6%. The palmar cutaneous branches of the median and the ulnar nerves in the palmar region were classified as Type A (34%), Type B (13%), Type C (13%), Type D (none), Type E (40%) according to forms of palmar cutaneous innervation originating from the ulnar and median nerves. Injury to the palmar cutaneous branch of the median nerve (PCBMN) is the most common complication of the carpal tunnel surgery. Various techniques were described to decrease post-operative morbidity. Based on these anatomic findings mini incision between the superficial palmar arch and the most distal part of the PCBMN in the palmar region is the safe-zone for carpal tunnel surgery.

Angiolymphoid hyperplasia: a case of a rare arterial involvement and successful recurrence treatment with laser therapy.

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The incidence of accessory navicular bone types in Turkish subjects

Accessory ossicles are the skeletal variations of the ankle and foot that can cause painful syndromes. The accessory navicular bone is one of the most common accessory ossicle of the foot (4–21%) and is also known as os tibiale, os tibiale externum and os naviculare secundarium. This bone can be adjacent to the posteromedial tuberosity of the navicular bone or can be separated and may cause various diseases in the foot and mimic fractures of foot bones. The aim of this study was to document a detailed investigation of incidence and types of accessory navicular bones of Turkish subjects according to sex in both extremities. The accessory navicular bone was detected (11%) via the posterior–anterior radiographs of 650 subjects in the radiological examination. The incidences of accessory navicular bones were identified as 6.1–4.9% in female and male participants. Accessory navicular bones were classified into three groups as Type I, Type II and Type III and the incidences of these bones were determined as 3.3, 3.1, 4.6%, respectively. Each group was also divided into subgroups. The incidences of the subgroups are as Type Ia 0.6%, Type Ib 1.5%, Type Ic 1.2%, Type IIA/a 0.8%, Type IIA/b 0.4%, Type IIA/c 0%, Type IIB/a 1.1%, IIB/b 0.3%, IIB/c 0.5%, Type IIIa 1.5%, Type IIIb 1.4%, Type IIIc 1.7%. Finally, the types of accessory navicular bones were discussed and the imaging modalities for diagnosis were presented.

Innervated Digital Artery Perforator Flap

PURPOSE To describe a technique for covering defects of the fingertips: the innervated digital artery perforator (IDAP) flap. METHODS A total of 17 patients were treated with an IDAP flap. The size of the flaps varied between 2 ×1 cm and 3.5 × 2 cm. Postoperative evaluation of the patients consisted of the Semmes-Weinstein Monofilament test, static 2-point discrimination, patient satisfaction, extension loss, and an investigation into complications. RESULTS All IDAP flaps survived completely, and no patients required secondary interventions. The mean follow-up period was 7 months (range, 6-10 mo). The Semmes-Weinstein monofilament test results ranged from 3.22 to 3.84. The static 2-point discrimination in the flaps ranged from 2 mm to 4 mm (mean, 3.4 mm) compared with a range of 2 mm to 3 mm (mean, 2.7 mm) on the contralateral hand. There were no joint contractures in the reconstructed fingertips, although 2 patients developed mild hook nail deformity. One patient experienced mild cold intolerance, and 1 patient exhibited mild postoperative hypersensitivity. CONCLUSIONS The advantages of the IDAP flap include minimally invasive surgery; a reliable, versatile flap; and the ease of the technique for different-sized fingertip defect reconstructions with few complications. The IDAP flap may be useful in fingertip amputations when the amputated part is not suitable for replantation. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Congenital dislocation of the extensor tendon of the hand

Abstract Congenital dislocation of the extensor tendon is extremely rare. We report a case of bilateral dislocations in an 8-year-old boy, which were treated successfully with reconstruction of the sagittal band. We describe the technique and 18 months’ result.

Innervated Digital Artery Perforator Flap: A Versatile Technique for Fingertip Reconstruction

PURPOSE To demonstrate the advanced use of innervated digital artery perforator (IDAP) flaps for fingertip reconstruction. METHODS From August 2011 to May 2014, 65 fingers (59 patients) underwent fingertip or finger stump reconstruction using IDAP flaps. Sixty-one fingers from 55 patients who were followed up for more than 6 months were included in this study. The objective outcomes of patient evaluations consisted of the results of static 2-point discrimination tests, Semmes Weinstein monofilament tests, and extension loss tests. The subjective patient outcome evaluations consisted of the results of hypersensitivity and cold intolerance tests and patient satisfaction. RESULTS All flaps survived completely, and no patients required early secondary interventions. The mean follow-up period was 18 months (range, 6-36 months). The static 2-point discrimination in the flaps ranged from 2 to 6 mm (mean, 3.5 mm) compared with a range of 2 to 3 mm (mean, 2.5 mm) in the contralateral hands. The Semmes Weinstein monofilament test results ranged from 0.07 to 1.4 g compared with 0.04 to 0.4 g for the contralateral hand. One patient exhibited mild extension loss in the reconstructed finger, 4 patients experienced mild cold intolerance, and 2 patients exhibited mild hypersensitivity. CONCLUSIONS The IDAP flaps are sensitive, reliable, and versatile and should be considered for reconstructing acute fingertip defects. The use of IDAP flaps for revisions of previously reconstructed defects is also possible. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Sesamoid Disorders of the Hand

In B ri ef T HE TERM SESAMOIDS WAS USED FIRST BY Galen to describe the resemblance of the small rounded digital bones to sesame seeds. Sesamoid bones are usually round or oval-shaped bones, a few millimeters in diameter, that developed from their own ossification center. They are partially or totally embedded in the substance of a corresponding tendon. Most people have five sesamoid bones in each hand; two at the metacarpophalangeal (MCP) joint of the thumb, one at the interphalangeal (IP) joint of the thumb, one at the MCP joint of the index finger (MCP-II), and one at the MCP joint of the small finger (MCP-V). There can be different variations in each hand, however (Fig. 1). The incidence of sesamoid bones of the thumb is reported to be between 98% and 100% in the MCP joint and 22% and 73% in the IP joint. The prevalance and distribution of sesamoids in the hands is also variable between different populations and ethnic groups. Pathological conditions of the sesamoid bones are clinically underestimated. Physicians may pay little attention to sesamoid bones and consider them clinically unimportant anatomic variations, although they can become symptomatic. Trauma (fractures, dislocations), degenerative disorders, tumors, and avascular necrosis are the most common disorders of the sesamoid bones. This article describes the clinical importance of the sesamoid bones and possible pathological conditions. Understanding the possible disorders of the sesamoid bones of the hand can lead to a more accurate diagnostic process.

Reconstruction of fingertip defects with digital artery perforator flap

OBJECTIVE The aim of this study was to present our findings for the use of the digital artery perforator (DAP) flap in the covering of digital pulp defects. METHODS The study included 15 patients who underwent reconstruction of the fingertip using a DAP flap between July 2007 and February 2012. The blood supply of the perforator island flap was based on the distal and either radial or ulnar sides of the digit. Donor sites were closed using skin grafting in all cases. Static two-point discrimination (s2PD) and Semmes-Weinstein monofilament (SWM) testing was performed at the final follow-up to determine extension loss and sensorial improvement. RESULTS Mean follow-up was 22 (range: 7 to 62) months. Flaps size was between 2 x 1 cm and 2.5 x 1.5 cm. Temporary venous congestion was observed in 12 of the 15 patients and was without complication. All patients returned to their normal daily activities and work within an average of 39 (range: 30 to 45) days. Mean two-point discrimination was 5.3 mm and SWM test results were between 3.61 and 4.56 at the final follow-up. CONCLUSION The DAP flap appears to be a reliable procedure with several advantages as a single-stage operating procedure, easy to harvest, good sensory recovery and preservation of digital arteries.

A new technique for aneurysmal bone cysts of the proximal humerus: cortical collapsing

OBJECTIVES We evaluated the results of a new technique developed for aneurysmal bone cysts centrally located in the proximal humeral metaphysis leading to widespread destruction. METHODS The study included seven patients (5 boys, 2 girls; mean age 12.8 years; range 9 to 15 years) who were treated with cortical collapsing and massive fibular autograft for centrally located aneurysmal bone cysts in the proximal humeral metaphysis leading to widespread destruction. All the patients had type II and active tumors according to the criteria of Capanna et al. and Campanacci et al., respectively. Final evaluations included six patients because one patient was lost to follow-up. The mean follow-up period was 49 months (range 12 to 105 months). RESULTS No complications were seen in the early postoperative period. Radiographic examination showed partial recurrence in two patients; of whom, one patient underwent curettage and bone grafting in the postoperative second year because of pain and discomfort. No deformity was observed. One patient developed shortening of 0.5 cm. Radiographically, all the patients exhibited metaphyseal remodelling one year after surgery. Function of the shoulder joint was near-normal in all the patients. CONCLUSION In this technique, cortical collapsing reduces the amount of bone graft used, and massive fibular strut grafting provides structural support to prevent deformities.

Deep Palmar Tumors of the Hand

Purpose: Tumorous conditions of the hand are frequently encountered by hand surgeons. Deep palmar tumors of the hand are very rare, reported cases were usually benign, but the most important issue is frequent anatomical variations with challenging surgical exposure and excision of these lesions. When we review the literature, only case reports or small series of patients were reported. The aim of this study was to demonstrate our experience with the deep palmar tumors of the hand. Materials and Methods: A multicenter retrospective analysis was designed. Medical records were reviewed with searching the database of two hospitals. Fifty-one cases were identified who were operated between the period of January 1998 to May 2015, and patients were invited for final examination. Forty-three patients who were available for the final follow-up examination were included in the study. All patients were evaluated with physical examination and preoperative magnetic resonance imaging (MRI) for surgical planning; x-ray studies were obtained if necessary. Recurrences were confirmed with physical examination and MRI. The analyzed parameters include age, gender, localization, preoperative symptoms, size, site, treatment methods, histopathologies, complications of surgery, and recurrences. Palmar space was divided in to five zones: thenar, carpal tunnel, hypothenar, distal radial, and distal ulnar. Statistical analyses were performed. Results: The mean age at the operation was 38.5 (9-83). Twenty-one (49%) male and 22 (51%) female participants were included in the study. Nineteen (44%) right and 24 (56%) left hands were involved. The most common preoperative symptom was enlarging mass in all patients (100%) followed by nerve compression in 24 patients (44%; 2 motor involvement at Guyon canal), functional impairment in 12 patients (28%), pain in 5 patients (12%), and pruritus in 1 patient (2.3%). The mean follow-up period was 56.7 months (12-168). All 43 pathologies were benign, and there were 10 lipomas (23.3%), 8 ganglions (18.6%), 5 giant cell tumor of the tendon sheath (11.6%), 4 schwannomas (9.3%), 3 hemangioma, 3 palmar fibromatosis, 2 epidermal cysts (4.6%), 2 neurofibroma (4.6%), 1 angiolymphoid hyperplasia with eosinophilia (ALHE) (2.3%), 1 granuloma, 1 calcifying aponeurotic fibroma (CAF), 1 digital fibroma, 1 foreign body granuloma, and 1 lipofibromatous hamartoma. The most common complication was temporary numbness, and paresthesias of the digital nerves were detected in 10 (23%). Only 3 (7%) recurrences (2 ganglions and a lipoma) were observed in the postoperative first year. Two cases were re-operated and one case with ganglion was refused reoperation and followed up with the recurrence. Iatrogenic arterial injury in 2 patients (4.6%) were primarily repaired intraoperatively, local tenderness in one patient (2.3%), weakness of fifth finger adduction in one patients, and stiffness of index finger in one patient. Conclusion: Updated knowledge and understanding nature and demographic characteristics of the tumorous conditions of the hand is crucial for an accurate diagnosis and appropriate treatment. In the deep palmar space of the hand, tumors usually occurs close relationship between tendons, muscles, nerves, and vascular structures. Preoperative MRI is essential for the diagnosis and the successful surgical planning.