Nazim Karalezli

The fascial band from semitendinosus to gastrocnemius: the critical point of hamstring harvesting An anatomical study of 23 cadavers

Background Arthroscopically-assisted reconstruction of the anterior cruciate ligament with hamstring tendons has achieved widespread acceptance; however, the anatomy of these tendons may cause technical problems at harvesting. Methods We studied the anatomy of the fascial band between semitendinosus and gastrocnemius and the distance between the semitendinosus insertion and the origin of this band in 23 knees from cadavers (17 male). The length of the semitendinosus tendon and the width of the fascial band were also recorded. Results Fascial attachment was detected in all cadavers except 1. The mean width of the band was 2.6 (1–4) cm. The mean distance from the insertion of the semitendinosus to the fascial band was 7 (6–8) cm. The mean length of the semitendinosus tendon was 22 (18–26) cm. Interpretation A better understanding of the anatomy of the hamstring tendons will reduce the risk of a disappointing complication right at the start of the operation.

Extension Block Pinning Versus Hook Plate Fixation for Treatment of Mallet Fractures

PURPOSE To compare the outcomes and associated costs of the treatment of mallet fractures with either extension block pinning or open reduction and hook plate fixation. METHODS We treated 22 patients for a mallet fracture that involved at least 25% of the distal phalanx articular surface. Three joints demonstrated concomitant volar subluxation. Extension block pinning was used to treat 16 fractures (group 1) and 6 were treated with open reduction and hook plate fixation (group 2). All patients were evaluated at the second, fourth, and sixth weeks after surgery. Collected data included range of motion, extensor lag, and pain status. Patients were asked to grade preoperative and postoperative pain levels on a visual analog scale. Functional outcomes were determined by Crawford criteria. We retrospectively performed a cost analysis using our institutional records. RESULTS Mean follow-up was 12.7 months. Visual analog scale pain scores improved by a similar amount for both groups. Preoperative pain scores were 7.0 for group 1 and 7.5 for group 2. Postoperative levels were 2.0 and 2.0, respectively. Mean extensor lag was identical for both groups, 5°. Mean flexion was 70° for group 1 and 80° for group 2. Based on the Crawford criteria, group 1 had 5 patients rated as excellent, 6 as good, 3 as fair, and 2 as poor. Group 2 outcomes were 2 excellent, 2 good, and 2 fair. Five complications occurred in group 1, and 1 in group 2. Differences noted between groups were not statistically significant. Extension block pinning was more cost-effective than hook plate fixation. CONCLUSIONS We find extension block pinning to be an equally effective but more cost-efficient treatment than open reduction and hook plate fixation. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

The Concomitant Presence of Two Anomalous Muscles in the Forearm

This article describes the concomitant presence of two anomalous forearm muscles in a 20-year-old man, discovered accidentally during an operation for a forearm injury. The first one was similar to a reverse palmaris longus muscle except for its direction to the Guyon’s canal. The second one originated from the radial antebrachial fascia, superficial to all other forearm muscles in the lower half of the forearm, then diverged medially and extended into the Guyon’s canal and was innervated by the ulnar nerve. The patient had no symptoms related to overcrowding of the Guyon’s canal before the injury. A hand surgeon should be well informed about the anatomic variations of the hand to be comfortable during surgical practice.

Triggering of the Digits After Carpal Tunnel Surgery.

IntroductionCarpal tunnel syndrome (CTS) and trigger finger may be seen simultaneously in the same hand. The development of trigger finger in patients undergoing CTS surgery is not rare, but the relationship between these conditions has not been fully established.The aims of this prospective randomized study were to investigate the incidence of trigger finger in patient groups undergoing transverse carpal ligament releasing (TCL) or TCL together with distal forearm fascia releasing and to identify other factors that may have an effect of these conditions. Materials and MethodThis prospective randomized study evaluated 159 hands of 113 patients for whom CTS surgery was planned. The patients were separated into 2 groups: group 1 (79 hands of 57 patients) undergoing TCL releasing only and group 2 (80 hands of 56 patients) undergoing TCL and distal forearm fascia releasing together. The age and gender of the patients, dominant hand, physical examination findings, visual analogue scale (VAS), and electromyography (EMG) results were recorded. Follow-up examinations were made at 1, 3, 6, 12, and 24 months for all patients. We noted development of trigger finger in the surgical groups, and its location and response to treatment. ResultsThe incidence of trigger finger development was statistically significantly different between group 1 and group 2 (13.9% and 31.3%, respectively). The logistic regression analysis of factors affecting the development of trigger finger posttreatment found that the surgical method and severity of EMG were significant, whereas the effects of the other factors studied were not found to have any statistical significance. ConclusionThere was an increased risk of postoperative trigger finger development in patients undergoing TCL and distal forearm fascia releasing surgery for CTS compared to those undergoing CTL only. There is a need for further studies to support this result and further explain the etiology.

Transverse Carpal Ligament and Forearm Fascia Release for the Treatment of Carpal Tunnel Syndrome Change the Entrance Angle of Flexor Tendons to the A1 Pulley: The Relationship between Carpal Tunnel Surgery and Trigger Finger Occurence

Purpose. The appearance of trigger finger after decompression of the carpal tunnel without a preexisting symptom has been reported in a few articles. Although, the cause is not clear yet, the loss of pulley action of the transverse carpal ligament has been accused mostly. In this study, we planned a biomechanical approach to fresh cadavers. Methods. The study was performed on 10 fresh amputees of the arm. The angles were measured with (1) the transverse carpal ligament and the distal forearm fascia intact, (2) only the transverse carpal ligament incised, (3) the distal forearm fascia incised to the point 3 cm proximal from the most proximal part of the transverse carpal ligament in addition to the transverse carpal ligament. The changes between the angles produced at all three conditions were compared to each other. Results. We saw that the entrance angle increased in all of five fingers in an increasing manner from procedure 1 to 3, and it was seen that the maximal increase is detected in the middle finger from procedure 1 to procedure 2 and the minimal increase is detected in little finger. Discussion. Our results support that transverse carpal ligament and forearm fascia release may be a predisposing factor for the development of trigger finger by the effect of changing the enterance angle to the A1 pulley and consequently increase the friction in this anatomic area. Clinical Relevance. This study is a cadaveric study which is directly investigating the effect of a transverse carpal ligament release on the enterance angle of flexor tendons to A1 pulleys in the hand.

How do Different Sporting Activities Affect Bone Patella Volume?: A Descriptive Pilot Study

El objetivo de este estudio fue comparar el volumen de la patela en hombres sedentarios con la patela de deportistas de elite, incluyendo judokas, ciclistas, levantadores de pesas y atletas de taekwondo, miembros de equipos profesionales nacionales turcos. Los sujetos del estudio no tenian antecedentes o signos clinicos de una enfermedad ortopedica como la osteoartritis. Las rodillas derecha e izquierda de los individuos de todos los grupos se colocaron una al lado de otra, en posicion supina y fueron escaneadas por tomografia computarizada multidetector de alta resolucion. Las diferencias entre el volumen de la patela derecha e izquierda de los hombres sedentarios, atletas judokas, ciclistas, levantadores de pesas y atletas de taekwondo fueron estadisticamente significativas. El volumen promedio de la patela izquierda de un ciclista profesional y el volumen promedio de la patela derecha de un hombre sedentario fueron de maximo y minimo, respectivamente. Los resultados demostraron que el volumen de la patela de ciclistas fue significativamente mayor. De acuerdo a la literatura, el volumen del hueso de la patela fue asociado con una perdida anual de volumen del cartilago, razon por la cual el ciclismo en una edad temprana puede prevenir la perdida de cartilago de la patela en el futuro.

The Effects of Electrocautery on Peripheral Nerve: An Experimental Study.

BACKGROUND The aim of this study was to assess the usability of an electrocautery device as nerve stimulator and to investigate histopathologically the adverse effects of electrocautery at low power on rat sciatic nerves. METHODS A total of 36 female Sprague-Dawley albino rats were divided into six groups according to the power applied to their sciatic nerves (1, 2, 3, 4, 5 and 6 W, respectively). Pathologic changes were studied by microscopic examination and scored (no change = 0, mild = 1, moderate = 2, severe = 3). Multiple comparisons were provided for all groups by the Bonferroni test (one-way analysis of variance). A p value < 0.05 was accepted as statistically significant. RESULTS The average scores were 2.66 ± 0.51, 3.66 ± 0.51, 5.83 ± 1.83, 10.0 ± 1.78, 11.0 ± 1.54, and 13.8 ± 0.89 in groups 1 to 6, respectively. Significant differences were found between all groups (p < 0.01), except between groups 1 and 2, groups 2 and 3, and groups 4 and 5 (p > 0.05) Variable motor responses and foot deformities were observed at the different power levels. CONCLUSION Although electrocautery devices provoke motor responses if getting in contact with peripheral nerves as do nerve stimulators, their use induces histopathologically adverse effects even at the lowest power. Their use around peripheral nerves should be avoided.

Reverse Segond Fracture Variant Without Posterior Cruciate Ligament Injury Report of an Extremely Rare Case

Objectives: Reverse Segond fracture, which was described as the association of an avulsion of deep capsular portion of medial collateral ligament and tears of both posterior cruciate ligament (PCL) and medial meniscus, is an extremely rare injury, unlike Segond fracture. The aim is to report successful surgical treatment of a case with “Reverse Segond Fracture” with intact PCL. Methods: The patient was a 16 years old male, who admitted to emergency department of our Level I trauma center after a pedestrian traffic accident. The main complaint was pain on left knee and shoulder. Physical examination revealed mainly limitation in range of motion (ROM) of relevant joints. Radiology revealed Reverse Segond fracture in the left knee and associated left clavicula mid-shaft fracture. Imaging with MRI and CT revealed neither PCL injury or additional ligamentous pathologies of knee. MRI only revealed medial meniscus tear. Results: In surgery, avulsed bony portion of Reverse Segond fracture was fixed to tibia with a suture anchor and a cannulated screw securely under medial meniscus. Peripheral longitudinal medial meniscus tear was fixed with a 2-0 absorbable suture. Clavicle was internally fixed meanwhile. Knee range of motion (ROM) was started early on postoperative first day, then augmented progressively. The patient was mobilized partially-weight bearing after 1.5 months and returned to his active daily life after 2.5 months. He was without any residual complaints after a final follow-up period of 26 months. Conclusion: This case report would be evaluated as a Reverse Segond Fracture variant, as no injury to PCL was noted, in contrast to its original definition in the relevant literature, which is also scarse. To the best of knowledge, this is the first report of successful surgical treatment of a case with Reverse Segond Fracture variant without PCL tear in the relevant literature.

Is the rabbit knee a suitable model for the human interphalangeal and metacarphophalangeal joints of the hand

OBJECTIVES The purpose of this study was to assess the suitability of the rabbit knee as a small joint model for the human interphalangeal and metacarphophalangeal joints of the hand. METHODS The proximal joint surface areas of 47 middle phalanges, the proximal and distal joint surface areas of 90 proximal phalanges, and the distal joint surface areas of 42 metacarpals of various human cadavers were calculated and compared with the distal femoral and proximal tibial joint surface areas of 20 knee of 10 New Zealand white rabbits by a photogrammetric method. RESULTS The mean joint surface area of the rabbit proximal tibia was larger than the proximal joint surface area of the middle phalanx, the distal joint surface area of the proximal phalanx, the proximal joint surface area of the proximal phalanx, and the distal joint surface area of the metacarpal. The mean joint surface area of the rabbit distal femur was larger than that of the middle phalanx, but similar to the proximal joint surface area of the proximal phalanx, and that of the distal metacarpal and distal proximal phalanx. CONCLUSION The rabbit knee is not suitable model for the human interphalangeal and metacarphophalangeal joints of the hand. There is still a lack of an appropriate animal model for the small joints of the hand.