Ozgur Pilanci

Synovial chondromatosis of the metacarpophalangeal joint of the ring finger

Synovial chondromatosis is an uncommon condition, characterized by multinodular cartilagineous proliferation of the joint synovium. There are only a few case reports of synovial chondromatosis involving the hand in the literature. A case of synovial chondromatosis of the ring finger is reported in this paper.

Re: A benign Schwannoma of the digital nerve distal to the proximal interphalangeal joint

A 38 year-old labourer sustained distal radius and midshaft ulnar fractures after a fall. He was treated by open reduction and internal fixation of both bones elsewhere. The ulna was fixed with a dynamic compression plate and the distal radius with a fixed-angle volar plate (Hand Innovations, Miami, FL, USA). He presented to our clinic 2 2 years after surgery complaining of prominent painful hardware and wanted both plates removed. On physical examination, the patient was found to have tenderness to palpation over both plates. Under anaesthesia, the ulnar plate was exposed and removed without difficulty. The radial plate was exposed and the two proximal 3.5mm shaft screws removed with a standard large fragment screwdriver, without difficulty. However, removing the four distal fixed-angle locking 2.5mm partially threaded screws proved to be extremely difficult. One screw was removed with a power screwdriver after a few failed manual attempts. One screw could only be unscrewed by 2mm, after which it became lodged and would not loosen further. The other two screws were half removed until the point when the trailing threads began to engage the volar radial cortex, after which they also became lodged. Multiple tools were used in the attempted removal of the three screws to no avail, and the screws eventually became stripped. A last attempt was made to divide the screws with an osteotome between the plate and the radius, but this also proved ineffective and removal of the plate was abandoned. A Midas Rex metalcutting attachment (Medtronic, Minneapolis, MN, USA) was used to remove the prominent parts of the screws flush with the plate and to smooth the rough edges of the plate. The plate and buried portions of three screws were left in situ. Postoperative recovery was uneventful and, 6 months after surgery, he had recovered the same (functional) range of motion of the wrist and digital joints as pre-operatively, but with slight volar wrist pain. Volar plating of distal radial fractures has emerged as a popular method of treatment, and advocates of this technique of plating favour it over the dorsal approach as the fixed-angle device is less prominent and causes less tendon irritation or risk of tendon rupture (Smith and Henry, 2005). However, with increasing use, complications have also surfaced. Rupture of the flexor pollicis longus tendon is of most concern and has led some to support routine removal of volar plates (Drobetz and Kutscha-Lissberg, 2003). The exact reason why the screws could not be removed in this case is unclear. It is possible that a contributing factor was healing new bone formation under the plate. Perhaps because of the extended time since primary surgery (2 2 years), a new bone overgrew both the leading and trailing titanium screw threads. The partially threaded screws may have been responsible. It was possible to back out these relatively weak screw threads to the point where it seemed that the trailing threads were engaging the dense near cortex. Overgrowth of the cortex and/or inability of the partially threaded screws to back out through this cortex then prevented the screws from being retrieved. The purpose of this communication was not to dissuade colleagues from using volar plates, but to make the surgical community aware of this complication. Removal of these plates should be done only if absolutely necessary and with awareness of the possibility of difficulty in retrieving the distal screws.

Functional outcomes of preauricular underparotid retrograde approach for mandibular condyle fractures.

Management of condyle fractures includes a wide spectrum of alternatives including analgesia alone, physiotherapy, intermaxillary fixation, and open reduction and internal fixation. Various approaches have been previously mentioned for the access to the mandibular condyle. The aim of this retrospective clinical study was to evaluate our clinical results on preauricular underparotid retrograde approach for condylar fractures. This retrospective study included 20 condylar fractures in 16 patients who were treated surgically using a preauricular transparotid retrograde approach between 2010 and 2013. Functional outcomes with this method were addressed in light of the results obtained in this clinical series. We suggest this method in the management of condylar fractures.

Atypical presentation of tuberculous tenosynovitis of the hand.

Dear Sir, Tuberculosis (TB) may affect almost any body tissue. Musculoskeletal TB, which may affect bones, tendons and bursa, is a rare form of extrapulmonary disease and occurs in about 1.3% of cases (Lakhanpal et al., 1987). The diagnosis of TB tenosynovitis is often delayed. Typically, patients with TB synovitis describe local pain and have a swelling on the hand with limitation in the range of motion of the fingers (Lakhanpal et al., 1987; Sueyoshi et al., 1996). We report a case with atypical involvement of the hand. A 27-year-old butcher was referred to our clinic complaining of a painless swelling on the right hand for more than a year. Physical examination revealed hyperaemic palpable masses on the palmar surface of the thumb, the small finger and the ulnar region of the wrist. The limitations in the ranges of motion in the interphalangeal joint of the thumb and distal and proximal interphalangeal joints of the small finger were 10 , 20 and 25 , respectively. Soft tissue masses only were seen on radiographs, with no sign of bone destruction. MRI (post-contrast study) revealed heterogenous synovial lesions extending to the wrist around the flexor sheaths of the thumb and the small finger (Fig 1). Because of these findings, an open biopsy of the tenosynovium from the wrist was done. Macroscopically there was thickening of synovium accompanied by numerous rice-like particles. Histology showed granulomatous lesions containing multinuclear giant cells with occasional central necrosis, epitheloid fibroblasts and mononuclear inflammatory cells. These findings were characteristic of tuberculosis (Fig 2). Africanum and Bovinum types of tuberculosis were isolated by BACTEC. The patient was treated with antitubercular drugs (isoniazid, rifampin, pyrazinamide and ethambutol) for 9 months. The lesions regressed dramatically 6 weeks after starting these drugs. A nearly complete recovery of range of motion was observed at a 1 year follow-up. Further assessment of the patient and his family did not reveal any other physical or radiological evidence of the disease. Expect for a positive tuberculin test, all his routine biochemical tests were normal. There have been a few cases of flexor tenosynovitis caused by Mycobacterium bovis (Cooke et al., 2002). Most of them were related to occupation. In the light of our findings, we believe that the most likely source of contagion was an animal. To the best of the authors’ knowledge, this is the first case in which tuberculous tenosynovitis occurred in two different locations on the same hand.

Eyebrow reconstruction after tumor excision by using superficial temporal artery island flap.

number affects the firmness of the knot especially after the third throw and in multifilament suture materials. All of these methods have a learning curve including the use of specialized instruments in arthroscopic operations. On the other side, knot sliding using an instrument is a simple, reliable technique that uses the conventional knot tying technique that allows repeated throws. The knot is created outside the operation field, preventing accidental hooking of the knot to the other instruments. The main limitation of the knot sliding technique is that it is not appropriate for arthroscopic operations because of the small incisions that prevent a second instrument to enter into the operative field. However, using an additional mini-incision for the second device may also allow the entrance to closed fields to slide the knot. In our opinion, knot sliding is a useful method to simplify the conventional knot tying in deeper plane suturation.

Ectopic tooth superiorly located in the maxillary sinus.

FIGURE 3. Excised cyst wall and the tooth. process, palate, cheek, maxillary sinus, and the orbit are areas where ectopic teeth are usually observed. Dental volumetric incompatibility between the tooth and the dental arch, prolonged retention of primary teeth, presence of clefts, trauma, infection, ankylosis, cystic or neoplastic lesions, endocrine disorders, febrile diseases, iatrogenic activity, and exposure to radiation are known to be among the etiological factors leading to ectopic teeth. Although the condition is usually asymptomatic, chronic sinusitis is the main complaint of patients in cases where the ectopic tooth is connected to the sinus. A 41-year-old man presented with chronic sinusitis, which was present for the last 2 years. Because he complained that his condition did not improve despite the antibiotherapy, he underwent a computed tomographic (CT) imaging, which revealed an ectopic tooth located in the right maxillary sinus. The ectopic tooth was planned to be extracted under general anesthesia. Through a Caldwell-Luc incision, the anterior wall of the maxillary sinus was exposed. The anterior wall of the sinus was observed to be eroded because of the pressure resulting from the cyst. When a 1 1 window was formed through the thinned bone tissue, pulsation synchronous with the systemic pulse was observed at the border of the cyst. When the border of the cyst was excised, the bones of the posteromedial-lateral walls of the maxillary sinus were observed to be eroded. After the lavage, the operation was completed by placing a Penrose drain. The drain was removed on the third postoperative day. The histopathologic assessment of the excised mass did not indicate any malignancy. The cyst was defined as a dentigerous cyst. No problem or relapse was observed during the follow-up of the patient (Figs. 1–4). Dentigerous cysts are the most frequently observed ones among all follicular cysts, and they occur more commonly in males. The treatment of an ectopic tooth within the maxillary sinus involves its extraction because untreated cases may lead to the development of cysts or tumors, perforation of the orbital base, or obliteration of the nasal cavity. In our patient, the main problem was the erosion on the bones of the posteromedial-lateral walls of the maxillary sinus, which may be considered as an important barrier for complex arterial structures. The pulsation was a sign of the exposure of blood vessels, which could prove to be life-threatening. The bone erosion posteromedially from the maxillary sinus points to a possible

A Practical Solution for Preventing an Air Leak During Syringe-Assisted Liposuction

Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of

The use of bone wax for protection from sharp ends of interdental wires.

Sir, Mechanical irritation interdental loop wiring and intermaxillary fixation causes inflammation of oral mucosa, marginal gingiva and lips is virtually unavoidable in maxillofacial surgery.[1] Filippi et al. compared different types of splints (composite wire splinting, button bracket splinting, resine splinting and titanium trauma splinting) by means of irritation on gingival mucosa and lips. In their experimental study, they found that more irritation was caused by buton bracket splints on lips and by resine splint on gingival mucosa.[2]

An Uncommon Complication of Septorhinoplasty, Acute Dacryocystitis

During septorhinoplasty procedures lacrimal drainage systems are susceptible to injury because of the close relationship of the nasal bones. Most of the injuries to the system remain asymptomatic. Here we report a case of septorhinoplasty which was complicated by acute dacryocystitis postoperatively. The patient was treated successfully with appropriate medical therapy.

The Effects of Mucoperichondrial Flap Elevation on Septal L-strut Cartilage: A Biomechanical and Histologic Analysis in a Rabbit Model

Background: The harvesting of septal cartilage following mucoperichondrial flap elevation has almost become a standard step in rhinoplasty. However, the strength of the remaining septum has not yet been evaluated. In the current experimental study of a rabbit rhinoplasty model, the remaining septum following a graft harvest was analyzed both biomechanically and pathologically. Methods: Forty New Zealand rabbits were classified into four equal groups. Group 1 consisted of the animals in which unilateral elevation of the mucoperichondrial flaps was undertaken before the graft harvest, group 2 consisted of the animals in which bilateral elevation was undertaken, group 3 included the animals where the septum was exposed and left untouched after a bilateral mucosal flap elevation, and group 4 was designated as the control group. Specimens were analyzed under light microscopy for multiple parameters. Biomechanical analyses were performed with a universal testing device at the Department of Engineering, Biomechanical Laboratories, Istanbul Technical University. Results: Biomechanical analysis in terms of maximum tension revealed significant results among the groups (p = 0.008). Although insignificant results were observed overall using a pathologic analysis, the amount of chondrocytes was lower in group 2 than in group 1 (p = 0.099). The amounts of matrix collagen (p = 0.184) and fibrosis were (p = 0.749) higher in group 2 than in group 1. Conclusions: From these data, the authors conclude that mucoperichondrium integrity plays a crucial role in the biomechanical strength of the septum. More sophisticated studies with further pathologic analysis are required to determine the exact mechanism of strength loss observed with mucoperichondrial flap elevation.