Mustafa Ürgüden

Effect of Joint Motion on Safety of Portals in Posterior Ankle Arthroscopy

PURPOSE The purpose of this study was to determine the anatomic relation of the neural structures posteriorly crossing the ankle by use of classical ankle arthroscopy posterior portals and hindfoot endoscopy portals. The effect of ankle and hindfoot motions on portal-nerve distance was also determined. METHODS This study included 20 feet and ankles in 20 adult volunteers who had no complaints regarding their ankle joints. To obtain 6 fixed positions of the ankle and hindfoot (neutral-neutral, neutral-varus, neutral-valgus, dorsiflexion-neutral, dorsiflexion-varus, and dorsiflexion-valgus) during magnetic resonance imaging examination, feet were positioned in a polycaprolactone splint that was shaped before examination. Magnetic resonance imaging examinations were performed at all 6 positions, and the shortest distance between the sural and posterior tibial nerves to the portals was measured at 2 different levels. RESULTS The mean distance between the posterior tibial nerve and the posteromedial portal was 16.5 +/- 5.6 mm and that between the sural nerve and the posterolateral portal was 13.1 +/- 3 mm at the hindfoot portal level. At the level of the posterior ankle arthroscopy portal, the mean distance from the posterior tibial nerve to the posteromedial portal line was 13.3 +/- 4.6 mm and that from the sural nerve to the posterolateral portal line was 9.7 +/- 2.9 mm. The differences in distances were statistically significant (P < .001) according to the paired t test. We determined that the sural nerve approached the posterolateral portal in the dorsiflexion-varus (P = .026), dorsiflexion-valgus (P = .014), dorsiflexion-neutral (P < .001), and neutral-varus (P = .035) positions, and all differences were statistically significant. CONCLUSIONS We found that the posterior medial and lateral portals created at the level of the tip of the fibula as described by van Dijk et al. while the foot was in a neutral-neutral position provided the greatest margin of safety. We found no advantage of placing the ankle and hindfoot in different positions to avoid neurologic complications. CLINICAL RELEVANCE These findings suggest that neurovascular structures draw away from the posterior portals of ankle arthroscopy distally; by lowering the level of portals toward the tip of the fibula and positioning the foot at neutral, arthroscopic surgeons will decrease the risk of iatrogenic lesions.

Evaluation of the lateral instability of the ankle by inversion simulation device and assessment of the rehabilitation program

OBJECTIVES To assess the correctibility of the muscle atrophy, proprioceptive loss, and slowing of the reflex arc around the ankle after ankle sprain with rehabilitation. METHODS The study group consisted of 20 cases with chronic instability who had at least two episodes of ankle sprains (mean 20.6 years, range 16-32 years); control group consisted of 20 patients with same demographic characteristics but without instability. Isokinetic muscle strength measurements and proprioceptive evaluations were made using the Cybex device before and 1.5-month after rehabilitation period. Additionally, the inversion simulation device, which was developed together with the mechanical engineering department of our university, was correlated with the EMG device, and response periods of muscles to stimulation were measured. RESULTS The proprioceptive loss present in all cases with ankle instability before treatment significantly improved after effective rehabilitation (p=0.001). It was detected that lengthened peroneal latent periods shortened with effective rehabilitation (p=0.001). Cross-interaction of rehabilitation was shown with the preservation of the difference between the pathologic and normal sides regarding proprioception and peroneal latent periods before and after treatment, without any difference between the control group and the pathologic sides. CONCLUSION After ankle sprains, especially in patients with chronic instability, strengthening of the muscles around the ankle with well-planned proprioceptive exercises helps the patients return to normal living and sports activities, and prevents unnecessary surgery, especially in cases with functional instability.

Intrathoracic migration of Steinman wire

We report two cases of intrathoracic migration of Steinman wire used for the treatment of the fracture and shoulder dislocation. The migrations were symptomatic with back pain in our cases. The treatment involved removing of the pin via thoracotomy. The postoperative course was uneventful. Intrathoracic migration of Steinman wires should be expected in fixation of the shoulder problems. To avoid this complication, threaded pins have to be used in surgery of the shoulder region.

The role of bone scintigraphy in determining the etiology of heel pain

AbstractIn this study we aimed to determine the role of bone scintigraphy as an objective diagnostic method in patients with heel pain.67 heels of 50 of 182 patients with defined features who attended the orthopedics outpatient clinic with heel pain over a 3-year period, were treated with combined methods such as nonsteroidal anti-inflammatory drugs (NSAID) and contrast baths, stretching exercises and changing of footwear habits. A one year follow-up was established. The criteria identified by Wolgin et al. were used in assessing the results of the treatment.Subcalcaneal spur was demonstrated by radiography in 44 of the 67 heels. There were two different imaging patterns observed on three phase bone scintigraphy. Type I imaging pattern: Focal increased activity in the heel region or normal activity on dynamic and the blood pool phases and focal increased activity at the inferior calcaneal surface in the late static phase. Type II imaging pattern: Diffuse increased activity along the plantar fascia in the dynamic and the blood pool phase, and focal increased activity at the inferior calcaneal surface in the late static phase.There were 34 (50.7%) type I and 18 (26.8%) type II imaging patterns on the scans. Type I and type II imaging patterns were described as osseous and fascial respectively. At the final examination, the results for pattern type I were good in 16 patients (66.7%), fair in 6 patients (25%) and poor in 2 patients (8.3%), whereas in pattern type II results were good in 12 patients (80%) and fair in 3 patients (20%). The recurrence frequency was 4.1% and 6.6%, respectively.Subcalcaneal spur was determined in 70.5% of the patients with osseous pathology and 55.5% of the patients with fascial pathology. Based on this result, it can be ascertained that calcaneal spurs develop during the pathological process causing heel pain. Other findings supporting this claim were the differences in symptom periods of the patients with type I and type II imaging patterns and scintigraphies were normaly in 10 of 44 heels indicating subcalcaneal spurs on radiographies. These findings suggested that metabolic changes contributing to subcalcaneal spur were complete. Three phase bone scintigraphy is an objective method which can be used to diagnose heel pain, especially when determining the etiological factors and prognosis.In this study we aimed to determine the role of bone scintigraphy as an objective diagnostic method in patients with heel pain. 67 heels of 50 of 182 patients with defined features who attended the orthopedics outpatient clinic with heel pain over a 3-year period, were treated with combined methods such as nonsteroidal anti-inflammatory drugs (NSAID) and contrast baths, stretching exercises and changing of footwear habits. A one year follow-up was established. The criteria identified by Wolgin et al. were used in assessing the results of the treatment. Subcalcaneal spur was demonstrated by radiography in 44 of the 67 heels. There were two different imaging patterns observed on three phase bone scintigraphy. Type I imaging pattern: Focal increased activity in the heel region or normal activity on dynamic and the blood pool phases and focal increased activity at the inferior calcaneal surface in the late static phase. Type II imaging pattern: Diffuse increased activity along the plantar fascia in the dynamic and the blood pool phase, and focal increased activity at the inferior calcaneal surface in the late static phase. There were 34 (50.7%) type I and 18 (26.8%) type II imaging patterns on the scans. Type I and type II imaging patterns were described as osseous and fascial respectively. At the final examination, the results for pattern type I were good in 16 patients (66.7%), fair in 6 patients (25%) and poor in 2 patients (8.3%), whereas in pattern type II results were good in 12 patients (80%) and fair in 3 patients (20%). The recurrence frequency was 4.1% and 6.6%, respectively. Subcalcaneal spur was determined in 70.5% of the patients with osseous pathology and 55.5% of the patients with fascial pathology. Based on this result, it can be ascertained that calcaneal spurs develop during the pathological process causing heel pain. Other findings supporting this claim were the differences in symptom periods of the patients with type I and type II imaging patterns and scintigraphies were normaly in 10 of 44 heels indicating subcalcaneal spurs on radiographies. These findings suggested that metabolic changes contributing to subcalcaneal spur were complete. Three phase bone scintigraphy is an objective method which can be used to diagnose heel pain, especially when determining the etiological factors and prognosis.