Murad Uslu

Is there a safe area for the axillary nerve in the deltoid muscle? A cadaveric study.

BACKGROUND Several authors have defined a variety of so-called safe zones for deltoid-splitting incisions. The first aim of the present study was to investigate the distance of the axillary nerve from the acromion and its relation to arm length. The second aim was to identify a safe area for the axillary nerve during surgical dissection of the deltoid muscle. METHODS Twenty-four shoulders of embalmed adult cadavers were included in the study. The distance from the anterior edge of the acromion to the course of the axillary nerve was measured and was recorded as the anterior distance. The same measurement from the posterior edge of the acromion to the course of the axillary nerve was made and was recorded as the posterior distance for each limb. Correlation analysis was performed between the arm length and the anterior distance and the posterior distance for each limb. The ratios between arm length and the anterior and posterior distances were calculated for each case and were recorded as an anterior index and a posterior index. RESULTS The average arm length was 30.40 cm. The average anterior distance was 6.08 cm, and the average posterior distance was 4.87 cm. There was a significant correlation between arm length and both anterior distance (r = 0.79, p < 0.001) and posterior distance (r = 0.61, p = 0.001). The axillary nerve was not found to lie at a constant distance from the acromion at every point along its course. The average anterior index was 0.20, and the average posterior index was 0.16. CONCLUSIONS The present study describes a safe area above the axillary nerve that is quadrangular in shape, with the length of the lateral edges being dependent on the individuals arm length. Using this safe area should provide a safe exposure for the axillary nerve during shoulder operations.

Reliability of the safe area for the superior gluteal nerve.

The authors investigated the reliability of the safe area, which previously was defined to prevent injury to the superior gluteal nerve during the lateral approach to the hip, and its relation to body height. The distance between the point of entry of the superior gluteal nerve into the gluteus medius muscle and the greater trochanter, in the regions which were defined as the anterior and posterior halves of the muscle, were measured in 23 cadaveric hips. There was a significant correlation between the height of the cadavers and the distance in the anterior and posterior regions. In all of the anterior regions and 78% of the posterior regions of the hips, the superior gluteal nerve as found to be in the safe area. The current study showed that the average distance between the innervation point of the gluteus medius muscle and the greater trochanter might change as a function of body height. The risk of damage to the superior gluteal nerve may be higher if the direct lateral approach to the hip is used. These data show that it is possible that the safe area is not always safe.

Simultaneous bucket handle tear of both medial and lateral menisci of a knee with chronic anterior cruciate ligament deficiency.

Bucket handle meniscus tears constitute about 10% of all meniscal tears. Bucket handle tears of medial meniscus is three times more than lateral meniscus. Most of these tears are associated with anterior cruciate ligament (ACL) deficiency. Lateral meniscus lesions are more common with acute ACL deficiency, where medial meniscus lesions are more associated with chronic ACL deficiency. We identified bucket handle tears of each meniscus of a 30-year-old male patient while performing diagnostic arthroscopy during ACL reconstruction procedure. We present an ACL deficient knee with bucket handle tears of medial and lateral meniscus of the same knee and discuss the treatment.

Quadrilateral Space Syndrome Caused by a Humeral Osteochondroma: A Case Report and Review of Literature

Quadrilateral space syndrome (QSS) is a rare condition in which the posterior humeral circumflex artery and the axillary nerve are entrapped within the quadrilateral space. The main causes of the entrapment are abnormal fibrous bands and hypertrophy of the muscular boundaries. Many other space-occupying causes such as a glenoidal labral cyst or fracture hematoma have been reported in the literature. However, we could not find a report on classical QSS caused by an osteochondroma. The aim of this case report is to attract attention to an unusual etiology of shoulder pain, and to emphasize the importance of physical examination and x-ray imaging before performing more complex attempts for differential diagnosing.

Common complications of segmental bone transport with Ilizarov technique in defective tibia pseudoarthrosis: a review

In tibial pseudoarthrosis, segmental bone transport with Ilizarov external fixator is being widely applicated all around the world, with encouraging successful outcomes. As the treatment with this technique requires a long period of time, the surgeon may face many problems which may negatively affect the final outcome. Pin tract infection, early or delayed consolidation, axial deviation and translation at the target area, skin inversion, rupture of the bone by the wires and joint contractures or stiffness form the main and common clinical problems. The rate of failure and complications with Ilizarov method used for diaphysial bone defects are so rare when precise technical details are carried out. With other treatment modalities, it is usually too difficult to obtain union synchronously with infection eradication. Thus, the Ilizarov technique presents successful outcomes against some complications mentioned above. Segmental bone transport is a surgical technique in which some of the problems can never be prevented. However, close patient follow up and always keeping the problems in mind make early diagnosis possible. With the early recognition of problems, successful treatment and increased overall outcome can be expected.RésuméDans le traitement des pseudarthroses du tibia, le transfert osseux grâce au fixateur externe d’Ilizarov est largement utilisé dans le monde entier avec des succès encourageants. A cause de la longueur du traitement, le chirurgien doit faire face à de nombreux problèmes qui risquent d’affecter le résultat final. L’infection des broches, la consolidation trop précoce ou au contraire retardée, la déviation axiale ou la translation dans la zone cible, l’invagination cutanée, la fracture osseuse par la rétraction articulaire ou la raideur sont les problèmes les plus courants et les plus importants. Le taux de complications pour la méthode d’Ilizarov appliquée aux défects diaphysaires est en fait rare lorsque la technique est utilisée de façon précise dans ses moindres détails. Avec d’autres méthodes il est souvent difficile d’obtenir la consolidation osseuse de façon synchrone avec l’éradication de l’infection. La technique d’Ilizarov permet des succès malgré les complications citées plus haut. Le transfert osseux segmentaire est une technique chirurgicale dans laquelle il n’est jamais possible de prévenir toute complication. Mais, le suivi rapproché des patients et le fait d’avoir continuellement ces problèmes à l’esprit, permet le diagnostic précoce de ces complications. Grâce à cette reconnaissance précoce des problèmes, on est en droit d’espérer un résultat favorable malgré tout.

Bilateral osteochondritis dissecans of lateral femoral condyle

A 20-year-old male with bilateral osteochondritis dissecans (OD) of the distal lateral femoral condyle is presented. OD can occur in many joints; however, the medial femoral condyle of the knee is the most common. Bilateral OD of the distal lateral femoral condyle is extremely rare. In our case, the lesion on the right side was traumatic and the lesion on the left side was self-induced. We performed open surgery for both knees. The fragments were stabilized with multiple Herbert screws. This case supports the theory that a defect in the ossification center of the distal lateral femoral condyle plays a role in the etiology of osteochondritis dissecans.

Experience with the surgical treatment of radial polydactyly in adults.

Purpose:The aim of this study is to investigate the functional and cosmetic outcome after surgical reconstruction in adult patients. Methods:Eleven hands of the 10 adult patients with radial polydactyly were treated surgically. Clinical and radiologic examination was performed and cases were classified according to the Wassel system. The outcome was evaluated according to the Modified Wood criteria. Results:Average age of the patients was 20 years (range, 19–23 years) and all patients were male. All of the patients were admitted with the social consequences of the cosmetic problems resulting from the anomaly. Cosmetic and functional results were excellent in 9 cases and good in 2 cases. Conclusion:The findings of this study revealed that radial polydactyly can be surgically reconstructed satisfactorily in adulthood. However, the fact that these patients were mainly admitted as a result of the psychosocial consequences of the cosmetic aspect of the anomaly, we concluded that regardless of age, surgery should not be delayed after diagnosis.

Can skin surface pressure under a cast reveal intracompartmental pressure

Abstract Although monitoring intracompartmental pressure (IP) under a cast is very important, it is not possible to measure it in every patient undergoing cast treatment. This study aims to answer the question of whether skin surface pressure (SSP) under a cast can reveal IP. A plaster cast was applied to a sculpted inflatable forearm model with dorsal and volar compartments. SSP under the cast was measured at five different localizations from both dorsal and volar sides of the model and compared to the corresponding IP. In the second experiment, a posterior tibial compartment syndrome model was created in both limbs of five rabbits. Correlation analysis was performed between IP and SSP under the cast. All of the SSP measurements taken from the dorsal and volar side of the sculpted forearm model correlated with IP. Mean correlation coefficient of the measurements was 0.995 (P = 0.000) (SD 0.002, range 0.992–0.999). SSP and IP correlation analysis in the posterior tibial compartment syndrome model of 10 limbs in five rabbits revealed a high correlation. The mean correlation coefficient was 0.973 (P = 0.000) (SD 0.024, range 0.916–0.997). Measuring the pressure between the skin and cast can monitor IP. SSP monitoring can help the physician, patient or parents in the follow-up of patients undergoing cast treatment.

Computerized tomography scout view for determining distal femoral resection angle in intramedullary instrumentation of total knee arthroplasty

This study aims to investigate the results of distal femoral resection by determining the difference between mechanical and anatomical axes of femur using computerized tomography (CT) scout views in pre-operative planning of total knee arthroplasty. CT scout view of the lower extremities was taken before and after the operation in 16 patients undergoing total knee arthroplasty. Distal femoral resection was performed according to the previously determined ideal resection angle (IRA) using intramedullary instrumentation. At post-operative scanogram, femoral component deviation (FCD) was measured. The results were statistically analyzed. The average IRA was 6.95 (5–9) degrees. At post-operative measurements, the average FCD was 0.63 (0–3) degrees. CT scout films improve the accuracy in distal femoral resection and femoral component alignment.

Histological and magnetic resonance imaging alterations after irradiation of meniscus using Holmium:YAG laser.

OBJECTIVE The authors performed an experimental and a prospective clinical study to evaluate the histological and magnetic resonance imaging (MRI) alterations after irradiation of meniscus using holmium:YAG (Ho:YAG) laser VersaPulse Select 60 watts and InfraTome Delivery Systems 30 degrees Handpiece (spot size at fiber tip 0.4 mm; Coherent Medical, Palo Alto, CA). BACKGROUND DATA Recently, some authors reported a few cases with articular cartilage damage or paraarticular osteonecrosis following arthroscopic knee surgery in which the laser was used to assist in the treatment of meniscal pathology. METHODS Meniscus specimens in saline immersion were exposed to Ho:YAG laser irradiation. The laser wavelength was 2.1 microm and pulse duration was 250 microsec. Power settings were 1-1.5 joules per pulse and 10-15 Hz. Total laser energy used in these procedures was 2, 3.5, and 6 K joules. Eight patients with meniscal problems underwent arthroscopic partial meniscectomy using Ho:YAG laser. Total laser energy used for these surgeries was 1.5-2.5 K joules. MRI was performed preoperatively and at 6 months postoperatively. RESULTS At higher energy levels (more than 3 K joules), separation of the gap between the collagen fibers, and a three-dimensional dispersion in the striation were observed on electron microscopic evaluation of meniscus specimens. No patient had abnormal signals in MRI (a sign of articular cartilage damage or osteonecrosis) following arthroscopic laser surgery. CONCLUSION When higher energy level is required, conventional instruments should be preferred in the treatment of meniscal lesions. Laser should be reserved for the posteriorly located and smaller meniscal lesions.