Kahraman Ozturk

Tibialis posterior tendon transfer for persistent drop foot after peroneal nerve repair.

Despite advances in the surgical treatment of peroneal nerve injuries, a significant fraction of patients do not recover adequately. Among 35 patients who had previous repair of the peroneal nerve, 19 had permanent drop foot, and 16 of these patients underwent tibialis posterior (TP) tendon transfer. Mean duration of paralysis was 26.7 (range, 7 to 192) months. TP tendon was carried to the anterior compartment via the circumtibial route, and then attached to the tibialis anterior, extensor hallucis longus, extensor digitorum communis, and peroneus tertius tendons using tendon-tendon anastomosis. All patients except for one achieved active dorsiflexion to or beyond neutral. Mean preoperative drop foot angle increased from -33.8 degrees to + 9.7 degrees. According to the Stanmore system, the results were excellent in 10 patients (62.5%), good in 4 (25.0%), fair in 1 (6.2%), and poor in 1 (6.2%). The average Stanmore score was 85, which corresponded to an excellent result. We believe that the TP tendon transfer is a straightforward and reliable solution in the treatment of drop foot.

Accuracy of intrasheath injection techniques for de Quervain’s disease: a cadaveric study:

The purpose of this study was to assess the accuracy of injections of dye into the first extensor compartment of the wrist using three different techniques in 150 wrists in 75 fresh cadavers. To compare injections, 50 wrists from 25 cadavers were used for each technique. After the injections, the first extensor compartment was dissected and the dispersion of dye around the abductor pollicis longus and extensor pollicis brevis tendons was investigated. In 72 % of all the wrists, acrylic dye was dispersed into one compartment containing both the abductor pollicis longus and extensor pollicis brevis tendons, but in 28% of the wrists there was a separate compartment for extensor pollicis brevis and dye entered only one of the compartments (14% for each compartment). For accurate injections, we think the injections should be made separately over the two tendons, to allow for the possibility of a septum within the compartment.

Results of Ray Resection and Amputation for Ring Avulsion Injuries at the Proximal Interphalangeal Joint

We investigated the long-term functional results of ray resection (14 cases) and amputation (nine cases) for ring avulsion injuries of ring finger which could not be replanted or underwent failed replantation. The mean follow-up was 37 (range, 24–63) months in the ray resection group and 32 (range, 24–40) months in the amputation group. Grip strength, key pinch strength, chuck pinch strength, hand circumference and palmar volume were decreased in the ray resection group but only grip strength and pulp pinch strength were significantly decreased in the amputation group. These results suggest that ray resection should be avoided in patients with occupations that need strong key and chuck pinch functions.

Coracoclavicular ligament repair and screw fixation in acromioclavicular dislocations.

OBJECTIVES We evaluated the long-term results of acromioclavicular dislocations treated with coracoclavicular fixation using a cancellous screw. METHODS Coracoclavicular fixation was performed using the modified Bosworth technique in 32 patients (24 males, 8 females; mean age 35 years; range 19 to 58 years) with acromioclavicular dislocations. According to the Rockwood classification, seven patients had type III, nine patients had type IV, 13 patients had type V, and three patients had type VI dislocations. Following repair of the coracoclavicular ligament, fixation was performed with a cancellous screw in all but two patients in whom a cortical screw was used. These two patients developed redislocation due to screw cut out and underwent reoperation with cancellous screw fixation and were not included in the final assessments. The screws were removed under local anesthesia after eight weeks postoperatively. The patients were evaluated for cosmetic appearance, functional status, pain, localized tenderness, articular range of motion, and with the functional Constant scoring system. The mean follow up was 3.1 years (range 1 to 8 years). RESULTS The mean Constant score was 98 (range 92 to 100). The results were excellent in 26 patients (86.7%) and good in four patients (13.3%). There was subluxation of the acromioclavicular joint in one patient (3.3%). The alignment of the acromioclavicular joint was normal in the remaining patients. None of the patients showed joint degeneration. All patients were pain-free and achieved full range of motion. CONCLUSION With ease of application, low complication rate, and low rate of acromioclavicular joint arthrosis, the modified Bosworth technique is an effective surgical method in providing satisfactory shoulder function in acromioclavicular dislocations.

Comparison of carpal tunnel injection techniques: A cadaver study

The purpose of the study was to evaluate the accuracy of injections into the carpal tunnel using three different portals in cadavers, and to define safe guidelines. In this study, 150 wrists of 75 cadavers (54 male, 21 female) were included. To compare three injection sites, 50 wrists of 25 cadavers were used for each technique; we used 23 gauge needles, and acrylic dye. The first injection technique: the needle was inserted 1cm proximal to the wrist crease and directed distally by roughly 45 in an ulnar direction through the flexor carpi radialis tendon. The second injection technique: the needle was inserted into the carpal tunnel from a point just ulnar to the palmaris longus tendon and 1cm proximal to the wrist crease. The third injection technique: the needle was inserted just distal to the distal skin crease of the wrist in line with the fourth ray. The first injection technique gave the highest accuracy rate, and this was also the safest injection site. Median nerve injuries caused by injection was seen mostly with the second technique. Although a steroid injection may provide symptomatic relief in patients with carpal tunnel syndrome, the median nerve and other structures in the carpal tunnel are at risk of injury. Because of that, the injection should be given using the correct technique by physicians skilled in carpal tunnel surgery.

Reconstruction of shoulder abduction and external rotation with latissimus dorsi and teres major transfer in obstetric brachial plexus palsy

Objectives: We evaluated the results of latissimus dorsi and teres major tendon transfer to the rotator cuff together with musculotendinous lengthening of the subscapularis and/or pectoralis major muscles in patients with internal rotation contracture and decreased external rotation and abduction secondary to obstetrical brachial plexus palsy. Methods: Thirty patients (18 boys, 12 girls; mean age 9 years; range 4 to 15 years) with internal rotation contracture and loss of external rotation and abduction of the shoulder secondary to obstetrical brachial plexus palsy underwent transfer of the latissimus dorsi/teres major tendons to the rotator cuff. In addition, musculotendinous lengthening of the subscapularis and pectoralis major (n=15), pectoralis major (n=9), and subscapularis (n=6) were performed. Nine patients had upper plexus involvement (C5-6), 14 had C5-7 involvement, and seven had complete plexus involvement (C5-T1). According to the Waters and Peljovich classification, all the patients had a congruent glenohumeral joint, which was classified as type 1 in one patient, type 2 in 15 patients, and type 3 in 14 patients. Pre- and postoperative range of motion values of the patients were measured and their motor functions were evaluated with the Mallet scoring system. The mean follow-up period was 47.8 months (range 9 to 84 months). Results: Preoperatively, the mean active abduction was 75.8°, and the mean active external rotation was 25.2°. Postoperatively, the mean abduction and external rotation increased to 138.3° (by 62.5°, 82.5%) and 76.4 degrees (by 51.2°, 203.2%), respectively. Improvements in the degrees of abduction and external rotation were significant (p=0.000). According to the Mallet scoring system, the mean preoperative global abduction and global external rotation scores were 2.97 and 2.43, respectively; the mean Mallet scores for the ability to move the hand to the mouth, neck, and back were 2.50, 2.17, and 2.67, respectively. Postoperatively, the mean global abduction score increased to 3.97 (by 33.7%, p=0.000), and the mean global external rotation score increased to 3.77 (by 55.1%, p=0.000). The mean scores for the ability to move the hand to the mouth, neck, and back were 3.30 (increased by 32%, p=0.000), 3.73 (increased by 71.9%, p=0.000), and 2.30 (decreased by 13.9%, p=0.003), respectively. Postoperative changes in the Mallet scores were all significant. Improvements in abduction and external rotation were not significant between patients ≤9 years and >9 years of age (p>0.05). Conclusion: Transfer of the latissimus dorsi and teres major tendons to the rotator cuff combined with musculotendinous lengthening of the subscapularis and/or pectoralis major provides satisfactory increases in shoulder abduction and external rotation, regardless of the age, in patients with no or minimal glenohumeral joint incongruency.OBJECTIVES We evaluated the results of latissimus dorsi and teres major tendon transfer to the rotator cuff together with musculotendinous lengthening of the subscapularis and/or pectoralis major muscles in patients with internal rotation contracture and decreased external rotation and abduction secondary to obstetrical brachial plexus palsy. METHODS Thirty patients (18 boys, 12 girls; mean age 9 years; range 4 to 15 years) with internal rotation contracture and loss of external rotation and abduction of the shoulder secondary to obstetrical brachial plexus palsy underwent transfer of the latissimus dorsi/teres major tendons to the rotator cuff. In addition, musculotendinous lengthening of the subscapularis and pectoralis major (n=15), pectoralis major (n=9), and subscapularis (n=6) were performed. Nine patients had upper plexus involvement (C5-6), 14 had C5-7 involvement, and seven had complete plexus involvement (C5-T1). According to the Waters and Peljovich classification, all the patients had a congruent glenohumeral joint, which was classified as type 1 in one patient, type 2 in 15 patients, and type 3 in 14 patients. Pre- and postoperative range of motion values of the patients were measured and their motor functions were evaluated with the Mallet scoring system. The mean follow-up period was 47.8 months (range 9 to 84 months). RESULTS Preoperatively, the mean active abduction was 75.8°, and the mean active external rotation was 25.2°. Postoperatively, the mean abduction and external rotation increased to 138.3° (by 62.5°, 82.5%) and 76.4 degrees (by 51.2°, 203.2%), respectively. Improvements in the degrees of abduction and external rotation were significant (p=0.000). According to the Mallet scoring system, the mean preoperative global abduction and global external rotation scores were 2.97 and 2.43, respectively; the mean Mallet scores for the ability to move the hand to the mouth, neck, and back were 2.50, 2.17, and 2.67, respectively. Postoperatively, the mean global abduction score increased to 3.97 (by 33.7%, p=0.000), and the mean global external rotation score increased to 3.77 (by 55.1%, p=0.000). The mean scores for the ability to move the hand to the mouth, neck, and back were 3.30 (increased by 32%, p=0.000), 3.73 (increased by 71.9%, p=0.000), and 2.30 (decreased by 13.9%, p=0.003), respectively. Postoperative changes in the Mallet scores were all significant. Improvements in abduction and external rotation were not significant between patients ≤ 9 years and > 9 years of age (p > 0.05). CONCLUSION Transfer of the latissimus dorsi and teres major tendons to the rotator cuff combined with musculotendinous lengthening of the subscapularis and/or pectoralis major provides satisfactory increases in shoulder abduction and external rotation, regardless of the age, in patients with no or minimal glenohumeral joint incongruency.

The effects of osteoporosis on functional outcome in patients with distal radius fracture treated with plate osteosynthesis.

OBJECTIVE The aim of this study was to evaluate the effect of osteoporosis on functional results in patients with distal radius fracture treated with plate osteosynthesis. METHODS The study included 37 female patients who underwent osteosynthesis using volar locking plate for distal radius fracture between 2006 and 2008. Diagnosis of osteoporosis was made with bone mineral density measurement. Patients were divided into two groups; Group 1 patients (20 patients; mean age: 56.5 years) had osteoporosis and a mean T-score of -2.6 SD, and Group 2 patients (17 patients; mean age: 37.1 years) did not have osteoporosis and had a T-score of -0.7 SD. Radiological results were evaluated according to the Stewarts criteria and activities of daily living were assessed with the modified Gartland and Werley score, the modified Mayo wrist scoring system, and the DASH scoring system. RESULTS According to the Stewarts radiological evaluation criteria and modified Gartland and Werley scores, there was no statistically significant difference between Group 1 and 2 (p>0.05). However, a statistically significant difference was found between Group 1 and 2 according to the modified Mayo wrist scoring system and DASH scoring system (p<0.05). CONCLUSION There was no radiological difference between the osteoporotic and non-osteoporotic patients with distal radius fractures treated with plate osteosynthesis. However, osteoporosis had a negative effect on the results and range of motion of the wrist, and activities of daily living were significantly restricted.

The versatile reverse-flow digital artery cross-finger flap.

Various flaps have been described for the reconstruction of the soft tissue defects of the digits, but these are not applicable to all kinds of defects. Moreover, these techniques are mostly 2-staged operations that require long-term immobilization. In this study, reverse-flow digital artery cross-finger flap was used to cover various volar and dorsal digital defects in 9 cases. Seven of 9 cases that had follow-up period longer than 2 years were evaluated, and all had good results. We recommend that reverse-flow digital artery cross-finger flap is a universal flap that can be used for almost all types of soft tissue defects of the digits.

Shoulder arthrodesis with plate fixation.

OBJECTIVE The aim of this study was to evaluate the long-term outcome of shoulder arthrodesis with plate fixation and primary autogenous grafting in terms of pain, functional status and arthrodesis position. METHODS The study included 8 patients (7 males and 1 female; mean age: 39.3 years; range: 22 to 68 years) who underwent arthrodesis with plate fixation and primary autogenous grafting. Mean follow-up period was 66.6 (range: 47 to 96) months. Five cases had traumatic brachial plexus palsy, 2 polio sequela and 1 sequela of an operated proximal humerus fracture due to a falling injury. One of the traumatic palsy cases was accompanied with a humerus shaft fracture. Arthrodesis was performed in all cases according to AO principles with plate fixation and primary autogenous grafting. Five of the paralytic patients also underwent Steindler flexorplasty. Follow-up assessments included monthly radiologic control for union, the visual analog scale (VAS) for pain and the Oxford shoulder score (OSS) for functional status. RESULTS Radiological fusion was seen in all cases in an average of 16 (range: 12 to 18) weeks, and arthrodesis was stable at physical examination. The accompanying humerus shaft fracture was also fixed with plate. One patient with traumatic palsy experienced a humerus fracture distal to the arthrodesis plate at the 8th postoperative month. An additional traumatic palsy case had flexion deformity at the wrist in the second year of follow-up and a wrist arthrodesis with dorsal plate was performed. One patient (12.5%) had a donor site infection on the tenth day after surgery. The target positions of 30° of abduction, 30° of forward flexion, and 30° of internal rotation were achieved with an average deviation of 7°. Mean active abduction was 68.1° (range: 55° to 90°), flexion was 67.5° (range: 60° to 85°), and internal rotation was at the level of trochanter major. The mean OSS was 35.9 (range: 32 to 40), and the mean VAS score was 2.9 (range: 1 to 7). CONCLUSION Our findings show that AO reconstruction plate and primary autogenous bone grafting is a safe and effective arthrodesis method that can also be used as a salvage procedure.

Cerebrotendinous xanthomatosis presenting with bilateral achilles tendon xanthomata: a case report.

Xanthomas are described as deposits in the skin and subcutaneous tissues. Mostly known as pseudotumors, xanthomas consist of connective tissue containing mainly cholesterol, triglycerides, and numerous foamy macrophages. Bilateral Achilles tendon xanthomata is pathognomonic for cerebrotendinous xanthomatosis in the case of normal cholesterol levels but increased cholestanol levels in serum. In this article, we present findings regarding bilateral xanthomas of Achilles tendons in a patient with cerebrotendinous xanthomatosis.