Ismail Bulent Ozcelik

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.

Synovial chondromatosis of the metacarpophalangeal joint of the ring finger

Synovial chondromatosis is an uncommon condition, characterized by multinodular cartilagineous proliferation of the joint synovium. There are only a few case reports of synovial chondromatosis involving the hand in the literature. A case of synovial chondromatosis of the ring finger is reported in this paper.

Late results of replantations in tip amputations of the thumb

OBJECTIVES We retrospectively evaluated replantations performed for Tamai type 1 thumb amputations. METHODS The study included 14 patients (12 males, 2 females; mean age 28 years; range 14 to 40 years) whose replanted thumbs survived following replantation for Tamai type 1 amputations in the distal nail fold of the thumb. Central digital artery anastomosis was performed in all the cases. Four patients with an appropriate vein had a single volar vein anastomosis. Nerve repair could be possible in only three patients. Sensory evaluations were made with the Semmes-Weinstein monofilament test, static and moving two-point discrimination tests, and vibration test. In addition, patients were evaluated with respect to atrophy in the replanted part, nail-bed deformities, and cold intolerance. The mean follow-up period was 11 months (range 6 to 48 months). RESULTS The Semmes-Weinstein test was green (range 2.83 to 3.22) in five patients (35.7%), blue (range 3.22 to 3.61) in eight patients (57.1%), and purple (range 3.84 to 4.31) in one patient (7.1%). The mean static and moving two-point discrimination test results were 6.9 mm (range 3 to 10 mm) and 4.5 mm (range 3 to 6 mm), respectively. Compared to the intact fingers, vibration was increased in six thumbs (42.9%), decreased in six thumbs, and the same in two thumbs (14.3%). Atrophy of the replanted parts was observed in five patients (35.7%). Three patients (21.4%) complained about cold intolerance, and three patients had nail-bed deformities. The mean time to return to work was 3.2 months (range 2 to 6 months). CONCLUSION Despite technical difficulties, thumb replantations yield good functional and aesthetic results. Sensory recovery is sufficient even after tip replantations without nerve repair.

Two-Suture Fish-Mouth End-to-Side Microvascular Anastomosis With Fibrin Glue

Abstract The most decisive step during free tissue transfers and replantation surgery may be respected as microvascular anastomosis. The conventional end-to-side anastomosis technique with simple interrupted sutures is well established and proven to be successful. On the other hand, conventional technique can be time consuming and can cause vascular thrombosis, vessel narrowing, and foreign-body reactions. Search for a more rapid and secure alternative to conventional technique is carried on. In this study, we defined a new technique for end-to-side anastomosis with fish-mouth incisions and application of fibrin glue and compared our results with those we obtained with conventional end-to-side anastomosis. We evaluated end-to-side anastomosis of carotid arteries of a total number of 64 Wistar-Albino rats. In control group (n = 32), conventional anastomoses with 8 to 10 sutures were performed. In experimental group (n = 32), fish-mouth incisions were applied first on the recipient artery, followed by performing anastomosis with only 2 corner sutures and applying commercially available fibrin glue. Time taken to perform the anastomosis was significantly shorter with the experimental group (P = 0.001), whereas early and late patency and aneurysm rates were comparable to those achieved with control group. Histological evaluation did not point out any significant differences between the groups. We have defined a rapid and safe alternative technique of end-to-side anastomosis with the use of fibrin glue. This method may be an alternative especially where multiple anastomoses are required or where it is difficult to approach anastomotic line, as it is easily performed, rapid, safe, and not involving any complex equipments.

Atypical presentation of tuberculous tenosynovitis of the hand.

Dear Sir, Tuberculosis (TB) may affect almost any body tissue. Musculoskeletal TB, which may affect bones, tendons and bursa, is a rare form of extrapulmonary disease and occurs in about 1.3% of cases (Lakhanpal et al., 1987). The diagnosis of TB tenosynovitis is often delayed. Typically, patients with TB synovitis describe local pain and have a swelling on the hand with limitation in the range of motion of the fingers (Lakhanpal et al., 1987; Sueyoshi et al., 1996). We report a case with atypical involvement of the hand. A 27-year-old butcher was referred to our clinic complaining of a painless swelling on the right hand for more than a year. Physical examination revealed hyperaemic palpable masses on the palmar surface of the thumb, the small finger and the ulnar region of the wrist. The limitations in the ranges of motion in the interphalangeal joint of the thumb and distal and proximal interphalangeal joints of the small finger were 10 , 20 and 25 , respectively. Soft tissue masses only were seen on radiographs, with no sign of bone destruction. MRI (post-contrast study) revealed heterogenous synovial lesions extending to the wrist around the flexor sheaths of the thumb and the small finger (Fig 1). Because of these findings, an open biopsy of the tenosynovium from the wrist was done. Macroscopically there was thickening of synovium accompanied by numerous rice-like particles. Histology showed granulomatous lesions containing multinuclear giant cells with occasional central necrosis, epitheloid fibroblasts and mononuclear inflammatory cells. These findings were characteristic of tuberculosis (Fig 2). Africanum and Bovinum types of tuberculosis were isolated by BACTEC. The patient was treated with antitubercular drugs (isoniazid, rifampin, pyrazinamide and ethambutol) for 9 months. The lesions regressed dramatically 6 weeks after starting these drugs. A nearly complete recovery of range of motion was observed at a 1 year follow-up. Further assessment of the patient and his family did not reveal any other physical or radiological evidence of the disease. Expect for a positive tuberculin test, all his routine biochemical tests were normal. There have been a few cases of flexor tenosynovitis caused by Mycobacterium bovis (Cooke et al., 2002). Most of them were related to occupation. In the light of our findings, we believe that the most likely source of contagion was an animal. To the best of the authors’ knowledge, this is the first case in which tuberculous tenosynovitis occurred in two different locations on the same hand.

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.

Advantages of using volar vein repair in finger replantations

Providing adequate venous outflow is essential in finger replantation surgeries. For a successful result, the quality and quantity of venous repairs should be adequate to drain arterial inflow. The digital dorsal venous plexus is a reliable source of material for venous repairs. Classically, volar digital veins have been used only when no other alternative was available. However, repairing volar veins to augment venous outflow has a number of technical advantages and gives a greater chance of survival. Increasing the repaired vein:artery ratio also increases the success of replantation. The volar skin, covering the volar vein, is less likely to be avulsed during injury and is also less likely to turn necrotic, than dorsal skin, after the replantation surgery. Primary repair of dorsal veins can be difficult due to tightness ensuing from arthrodesis of the underlying joint in flexion. In multiple finger replantations, repairing the volar veins after arterial repair and continuing to do so for each finger in the same way without changing the position of the hand and surgeon save time. In amputations with tissue loss, the size discrepancy is less for volar veins than for dorsal veins. We present the results of 366 finger replantations after volar vein repairs.

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.