Levent Altinel

Use of a splint following open carpal tunnel release: A comparative study

This study was undertaken to compare the clinical effectiveness and costs of postoperative splintage and late rehabilitation with a bulky bandage dressing versus early rehabilitation after carpal tunnel release. In this comparative study, 46 patients were randomly divided into 2 groups. In each group, 3 patients were excluded because of improper follow-up, leaving a total of 40 patients. Group 1 used a splint (exercises given 3 wk postoperatively) and group 2 was given a bulky bandage (exercises provided immediately) after open release. Patients were assessed preoperatively and at the first and third postoperative months with the Questionnaire of Levine for Clinical Assessment of Carpal Tunnel Syndrome. The 2 groups were similar in terms of preoperative functional status scores and in controls at the first and third months (P=.549,P=.326,P=.190). When both groups were compared, no statistical significance was found regarding symptom severity scale scores preoperatively and at the first postoperative month (P=.632 vsP=.353). At the third month, scores were lower in favor of group 2 (P=.023). Additionally, 16 of 20 patients (80%) in group 1 reported a heavy feeling and discomfort caused by the splint. This problem was not reported by the patients in group 2. The cheapest splint on the market was 9 times more expensive than a bulky dressing. The investigators concluded that postoperative immobilization with a splint has no detectable benefits. Use of bulky dressings and abandonment of the use of postoperative splints may prevent unnecessary expenditures without sacrificing patient comfort or compromising the course of healing in carpal tunnel surgery.

Clinical results versus subjective improvement with anterior transposition in cubital tunnel syndrome

This study was conducted to compare the results of anterior transposition methods and to determine the time needed to attain subjective well-being in patients with cubital tunnel syndrome. A total of 49 cases were retrospectively evaluated. Patients were called for follow-up, completed a questionnaire, and were reexamined. They were assigned to one of 3 groups: subcutaneous transposition (SCT), submuscular transposition (SMT), or intramuscular transposition (IMT). The McCowan classification and Wilson-Krout criteria were used for classification and outcomes assessments. Categorical variables were analyzed with the χ2 test, and metric variables by analysis of variance or through Kruskal-Wallis variance analysis. Improvement of at least 1 McCowan grade was observed in 87.63% of patients. The least responsive group was assigned a McCowan grade of III. The most effective procedure for resolving clawing was SMT. Clinical results were excellent in 26 patients (53.06%), good in 12 (24.48%), fair in 4 (8.16%), and poor in 7 (14.28%). At the latest follow-up, overall grip and pinch strength had improved by 23% and 34%, respectively, compared with the contralateral side. Thirty-six patients exhibited an improvement in grip power and 38 in fine dexterity. Complete resolution of numbness was observed in 32 patients, and complete resolution of pain was noted in 30 patients. The preoperative mean visual analog scale score of 6.82 improved to 3.36 postoperatively. Clawing improved in 4 patients and atrophy in 7. The mean time to subjective improvement was shortest in the SMT group and longest in the IMT group. The greatest pain relief was reported in the IMT group and the least in the SMT group. One case with IMT required reoperation because of recompression of the nerve. The most frequent complication in the SMT and IMT groups was muscular tenderness. In conclusion, SCT offers an alternative to other anterior transposition methods because of its simplicity and quicker recovery time, especially in mild to moderate cases.

HO prevention and the combined therapeutic protocol—do we really need it?

We would like to comment on the article by E.E. Pakos et al. entitled Prevention of heterotopic ossification in high-risk patients with total hip arthroplasty: the experience of a combined therapeutic protocol [5]. First, we would like to congratulate the authors for their contribution to the relevant literature. In the authors’ study, ankylosing spondylitis, hypertrophic osteoarthritis, diffuse skeletal hyperostosis, biochemical factors, male sex and a previous history of heterotopic ossication are defined as risk factors [5]. They also stated that this kind of study (combined radiotherapy and NSAID) has not been done before. They could not find a difference regarding the types of prosthesis, but found a statistically significant incidence of HO in females and in patients of osteoarthritis secondary to congenital hip dysplasia [5]. Heterotopic ossification (HO) is a common problem, especially after total hip replacement (THR) or after fracture treatment around the hip. n nWith a brief literature review, we found studies taking an opposing view to this study in which additional medication to radiotherapy caused no improvement of the clinical outcome [1]. Combined treatments were used post actebular fractures and were found to be effective [4]. The authors stated that male sex is a risk factor, but have found HO to be increased in females. At the end of their study, they did not provide an explanation for this phenomenon. In many studies, HO was found to be more frequent in male and elderly individuals, as well as in patients with primary osteoarthritis [6]. Also in other studies, a high body mass index, low preoperative range of motion, length of operative time and large osteophytes were defined as high risk factors [3]. This could be the reason why HO is more frequent in females in this study (DDH is more frequent and the operative time is lenghtened in these patients) [5]. n nThe author’s study is extremely valuable, but if they had a control group consisting of patients with isolated radiotherapy or an indomethacin group, then the comparison and distinction would be much easier. In some studies, even a single dose application of indomethacin was found to be effective in high-risk patients [2]. Also, this is the cheapest method of prophylaxis [2]. n nIn conclusion, regarding the prosthetic treatment of hip fractures or osteoarthritis, HO risk factors should be clearly identified to decrease morbidity with low costs of prophylaxis. In our clinic, we use the C-reactive protein levels as a postoperative predictor of HO. We also use indomethacine because of its low cost and effectivity, regardless of the HO risk group, with convenience both for HO prophylaxis and for pain control in the postoperative setting.

Effect of shed blood retransfusion on pulmonary perfusion after total knee arthroplasty: a prospective controlled study

Postoperative shed blood retransfusion (autotransfusion) is a commonly used salvage method following major surgical operations, such as total knee arthroplasty (TKA). The systemic effects of shed blood are still unclear. We studied the effect of residual substances in the retransfused shed blood, on lung perfusion after TKA. Fifteen unilateral and one bilateral TKAs were performed with autotransfusion (the study group) and 15 unilateral and three bilateral TKAs were performed in a control group. Lung X-rays, arterial blood gases (ABG), D-dimer values, and lung perfusion scintigraphies were performed preoperatively and postoperatively. A mean of 300.0u2009±u2009335.6xa0ml of bank blood was needed in the autotransfusion group and a mean of 685.7u2009±u2009365.5xa0ml of bank blood was needed in the control group (p=0.001). There was a postoperative segmental perfusion defect at the lateral segment of the superior lobe of the left lung in one patient of the control group and he also had risk factors for thrombosis. Although both groups had a decrease in lung perfusion postoperatively, there were no significant differences among the groups regarding the lung perfusion scintigraphy, chest X-rays, ABG, and D-dimer values. In conclusion, although pulmonary perfusion diminishes following TKA, shed blood retransfusion does not add any risk to pulmonary perfusion.RésuméLa retransfusion post-opératoire est souvent utilisée dans les interventions majeures comme les prothèses de genou. L’effet systémique du sang récupéré n’est pas très connu. Nous avons étudié les effets de cette transfusion sur la perfusion pulmonaire. 15 prothèses de genou unilatérales et une bilatérale étaient réalisées en autotransfusion avec un groupe de contrôle de 15 unilatérales et 3 bilatérales. Des radiographies pulmonaires, les gaz du sang, la valeur des D-dimer et des scintigraphies de la perfusion pulmonaire étaient faites avant et après l’opération. Une moyenne de 300,0+−335,6xa0ml de sang de banque était nécessaire dans le groupe autotransfusion et une moyenne de 685,7+−365,5xa0ml était nécessaire dans le groupe de contrôle (pu2009=u20090,001). Il y avait un déficit segmentaire de perfusion chez un patient du groupe de contrôle et il avait aussi des facteurs de risque thrombotique. Bien que les 2 groupes avaient une diminution de la perfusion pulmonaire, il n’y avait pas de différences entre les 2 groupes pour la scintigraphie pulmonaire, les radiographies, les gaz du sang et les valeurs des D-dimer. En conclusion, bien que la perfusion pulmonaire diminue à la suite de l’arthroplastie totale de genou, la retransfusion du sang répandu n’entraine pas de risque particulier.

Percutaneous resection of a patellar osteoid osteoma using a cannulated skin punch biopsy needle

Patella is a very rare localization for osteoid osteoma. Non-specific knee complaints and difficulty to distinguish nidus in direct radiographs may cause a delay in diagnosis and make the definite diagnosis troublesome. The most effective and non-invasive method in treatment of osteoma is CT guided excision of the nidus. We present a case of patellar osteoid osteoma diagnosed by MRI scans. After being marked under CT guidance, the lesion was completely excised with a skin punch. We propose that, this method is both minimal invasive and effective in the management of patellar osteoid osteoma.

Three-dimensional finite element analysis used to compare six different methods of syndesmosis fixation with 3.5- or 4.5-mm titanium screws: a biomechanical study.

BACKGROUNDnUse of thicker and longer (four cortices) screws or of multiple screws seems to be more stable and efficient for syndesmosis fixation.nnnMETHODSnA three-dimensional finite element model of an ankle was constructed from serial axial sections from an existing two-dimensional computed tomographic image. Constructions of syndesmosis fixation with 3.5-mm single tricortical, 3.5-mm single quadricortical, 3.5-mm double tricortical, 3.5-mm double quadricortical, 4.5-mm single tricortical, and 4.5-mm single quadricortical screws were performed on this model. Physiologic loads approximating those during stance phase normal walking were applied to this ankle system. Stress values on the screws using the six fixation methods were compared.nnnRESULTSnThe highest maximum stress was determined over 3.5-mm cortical screws applied as single quadricortical, and the lowest maximum stress was determined over the 4.5-mm cortical screw applied as single quadricortical. Stress on the 3.5-mm single screw with quadricortical application was found to be higher than that with tricortical application and also compared with the 4.5-mm quadricortical screw application. Differences between the 4.5-mm single tricortical and quadricortical screws and between the 3.5-mm single tricortical and 3.5-mm double tricortical screw applications were not significant.nnnCONCLUSIONSnQuadricortical application of 3.5-mm single screws and tricortical application of 3.5-mm double cortical screws are not good choices for syndesmosis fixation. If the plan is tricortical application, a 3.5-mm single cortical screw is adequate. If quadricortical application of syndesmosis fixation is planned, a 4.5-mm cortical screw should be used.

Easy retrieval of polyaxial tulip-head pedicle screws by "U" rod technique.

The number of fusion surgeries increase each year which also increase the need for implant removal. In some cases, it can be extremely hard to remove a pedicle screw especially when there is a mismatch of the screw and the screwdriver. Also the screwdrivers can be contaminated during the operation, and this will cause a delay till the instruments are re-sterilized. There is a need for the removal of screws without special instruments. We describe a method for removing tulip-head polyaxial pedicle screws without special instruments. The screws are removed using an Allen key, a rod bender and a “U” shaped rod. We successfully removed 76 screws in 11 recent cases without any complications. The “U” rod technique is a simple and useful technique for the removal of tulip-head polyaxial screws.

Bilateral post-injection fibrosis of the gluteal region mimicking lumbar disc herniation: a case report

Tissue fibrosis is a known complication of intramuscular injections, which is especially seen in children due to vaccinations and injections. Herein we report a case of post injection gluteal fibrosis that had undergone two unsuccessful lumbar discectomies to treat the symptoms of this disease. A 45 years old male patient was consulted to our clinic from the department of neurochirurgy with complaints of bilateral hip pain. The patient was operated on for lumbar disc herniation in L4–5 level twice but his complaints had not resolved. A third operation including L4–5 instrumentation and fusion was planned. His examination revealed nodules in his both hips. His x-rays, MRI and blood tests were normal. He underwent bilateral gluteal fascia excision and his complaints resolved totally. The clinical diagnosis of post-injection fibrosis is problematic, due to the difficulty of determining the etiology. In many patients the diagnosis comes from a history of injection. Pain in the gluteal region is not a frequently described clinical feature of this condition. Many reports in the literature emphasize a contracture rather than pain. Post-injection fibrosis in the gluteal region may mimic lumbar disc herniation and a detailed physical examination is the key for correct differential diagnosis. In refractory cases not responding to conservative treatment, surgical excision of the nodules may lead to a complete clinical recovery of the patient.

Treatment of distal radius fractures: the title or the conclusion?

I have read the article by Westphal et al. [1] with great interest and would like to congratulate them for their invaluable contribution to the literature regarding distal radius fractures. Distal radius fractures are one of the most commonly encountered fractures during daily practice [2, 3] and are one of the cornerstones of an orthopedic surgeon’s training. Appropriate management and treatment of these fractures are important to prevent long-term disability and sequels as may originate from the nature of the fracture or complication of the treatment method. Also, the comfort factor in the treatment throughout the healing process is of great concern nowadays. When evaluating the manuscript, I realized that there are some minor points to be mentioned. First of all, bearing in mind the conclusion part, the title of the manuscript seems a bit misleading. The title ‘‘no difference’’ and the manuscript concludes as ‘‘......palmar plating can also be recommended for the most common dorsal displaced distal radius fractures.’’ Thinking of the relatively shorter duration of healing, lesser frequency of complications and better results in subjective assessment, this study could be concluded in favor of palmar plating. Regarding the fracture type, both type A3 and C2 fractures have metaphyseal comminution and are prone to a dorsal tilt both during and at the end of the treatment. In Westphal’s study, this was one of the problems in the fixator group. We also faced the same problem among patients for whom we had used external fixators in our clinic. Also, determination of the need for grafting the fracture site and if found necessary, graft application, can be done using an open approach which is another benefit of palmar plating. The duration of the physical therapy in Westphal’s study, and also whether this duration was different for both groups is also unknown. Again, in our practice, external fixator patients always required a longer duration of physical therapy. Carrying an external fixator on one extremity is not easy. Wearing and taking off clothes and also the appearance of the extremity may all become problematic. Considering external fixation, adjuvant techniques like percutaneous pinning with K wires are also prone to complications like neural damage (especially superficial radial nerve) and again, pin tract infection [1, 4–6]. One point on which we strongly disagree is the recommendation of implant removal. In our routine practice, we inform the patient about the possibility of implant removal and its clinical implications but we have never performed a palmar plate removal to this date. There are economical aspects too. In our country, an anatomically shaped distal radius plate is about 20–30 times cheaper than an external fixator and this is one of the reasons for the preference given to internal fixation. To conclude, due to the advantages of direct vision of the fracture site, allowance of additional interventions like grafting, higher patient satisfaction, higher functional gains and lower number of complication rates together with cheaper cost of the operation, palmar plating seems to be the recommended treatment method as a result of this study. The lack of a prospective randomized trial is still the main obstacle for an appropriate solution.