Serdar Tüzüner

Results of zone II flexor tendon repair in children younger than age 6 years: botulinum toxin type A administration eased cooperation during the rehabilitation and improved outcome.

The inability of young children with a zone II flexor tendon repair to cooperate in postoperative care and rehabilitation may represent a high risk for medical and surgical complications. To forestall that risk, botulinum toxin type A (2.5 U/kg, 7 U/kg) injection was used during surgery to induce forearm flexor muscle relaxation in seven children under 6 years old with zone 2 flexor tendon repairs. Patients received a controlled passive motion regimen after surgery. Results were evaluated on the basis of the acquisition of muscle tone and active finger movements, total range of motion of affected joints, postoperative grip strength, muscle atrophy, and phalangeal length. In this prospective clinical study, the mean follow-up was 18 months. All the children had good and excellent results based on the Strickland criteria. As for postoperative complications, one patient had bowstring and another had poor finger sensibility and first web space contracture that required Z-plasty. The selective use of botulinum toxin type A to weaken the targeted muscles generated a sufficient reduction in spontaneous activity of the fingers, permitting an improved rehabilitation program. Botulinum toxin type A administration could be an effective form of therapy, serving as an alternative or adjunct to conventional rehabilitation modalities in these children.

Median nerve excursion during endoscopic carpal tunnel release.

OBJECTIVE:Restriction of the excursion of the nerve has been accepted as a pathogenetic element in carpal tunnel syndrome. The goal of this article was to evaluate the median nerve excursion in the carpal tunnel measured as a function of wrist position before and after endoscopic carpal tunnel release (ECTR) on 28 hands of 22 patients. METHODS:The position of cylindrical stainless steel markers embedded within the median nerve was measured by a direct radiographic technique. Each upper extremity was examined in three wrist positions. Then, endoscopic release with Menon’s technique was performed, and the measurements were repeated. RESULTS:In this prospective clinical study, most (93%) of the patients experienced resolution of their symptoms. Before and after ECTR, median nerve excursion was linear and was affected by wrist position. Before ECTR, when the wrist was moved from the end of dorsiflexion to the end of palmar flexion, the median nerve underwent a mean total excursion of 28.8 mm at the wrist. A comparison of the before and after ECTR excursion showed no statistical differences in the amount of motion. CONCLUSION:The single-portal ECTR does not seem to influence the median nerve excursion for the wrist positions studied in patients with carpal tunnel syndrome. The results from this in vivo study showed longitudinal gliding of the median nerve twice as great as in in vitro studies.

Changes in Tissue Substance P Levels in Patients With Carpal Tunnel Syndrome

BACKGROUND: Although carpal tunnel syndrome (CTS) is the most common entrapment neuropathy in adults, its etiology is not completely known. Chronic inflammation, fibrosis of the transverse carpal ligament (TCL), and altered sensory response contribute to the symptoms. OBJECTIVE: Because substance P (SP) is known to be involved in neuropathic pain, chronic inflammation, and fibrosis, the present study evaluated changes in SP levels in patients with CTS. METHODS: TCL, median nerve adventitia, and synovial connective tissue of the middle flexor digitorum superficialis tendon samples from patients (n = 42) with CTS and healthy control subjects (n = 13) who were operated on for hand wounds were obtained at surgery. A group of these patients with CTS (n = 9) had received meloxicam treatment for 10 days before surgery. A 2-step acetic acid extraction was used to determine changes in SP levels in free nerve endings (neuronal) and in nonneuronal cells. RESULTS: Changes in SP levels were observed in both neuronal and nonneuronal tissues. SP levels increased in extracts of the TCL and synovial connective tissue of the middle flexor digitorum superficialis tendon but not in the median nerve adventitia of patients with CTS. Meloxicam pretreatment increased SP levels in nonneuronal components of the TCL. CONCLUSION: These findings suggest that SP contributes to the pain and inflammation associated with CTS. Further studies are required to evaluate the therapeutic potentials of SP receptor (NK1R) antagonists in CTS.

Median nerve excursion in response to wrist movement after endoscopic and open carpal tunnel release.

PURPOSE To compare the perioperative kinematic effects of endoscopic versus open carpal tunnel release on longitudinal excursion (gliding) and volar displacement (bowstringing) of the median nerve at the wrist region in patients with idiopathic primary carpal tunnel syndrome. METHODS Sixteen hands of 13 patients were randomly assigned into 2 groups (group 1, endoscopic; group 2, open carpal tunnel release). For the measurement of gliding and bowstringing of the median nerve, a metallic marker was used. Before and after the division of the transverse carpal ligament, longitudinal excursion and volar displacement of the median nerve were calculated based on fluoroscopic imaging for each wrist. Movement was analyzed for the measurement of the marker locations. RESULTS The mean prerelease median nerve excursion during wrist range of motion was 20 mm (range, 10-28) in group 1 and 21 mm (range, 16-31 mm) in group 2. The mean postrelease median nerve excursion during wrist range of motion was 20 mm (range, 13-29) in group 1 and 18 mm (range, 8-26 mm) in group 2. There was no statistically significant difference in pre- and postrelease longitudinal excursion changes between the groups (p = .916 and p = .674, respectively). The mean prerelease volar displacement of the median nerve during wrist range of motion was 3 mm in group 1 and 4 mm in group 2; the postrelease mean values were 2 mm and 5 mm, respectively. There was no statistically significant difference between the groups with regard to pre- and postrelease volar displacement changes of the median nerve (p = .372 and p = .103, respectively). CONCLUSIONS This study demonstrated that the endoscopic release and open carpal tunnel release produce similar perioperative effects on longitudinal and volar movements of the median nerve.

Improvement of Zoledronic Acid-Induced Jaw Osteonecrosis with Bortezomib

month, but the painful mass on her mandible did not recover. The clinical course, CT and biopsy findings suggested that our patient had a zoledronic acid-induced jaw osteonecrosis [3, 4] . Two months after the cessation of antibiotic therapy, MM also relapsed. Bortezomib was started on days 1, 4, 8 and 11 at a dose of 1.3 mg/m 2 as monotherapy. After the first cycle of bortezomib, clinically regression of the mass and pain relief in her left jaw were observed in the absence of dexamethasone, antibiotic or any other drug treatment that could cause the improvement in osteonecrosis. This was an unexpected and surprising finding. If it were a plasmacytoma, it would reasonably respond to bortezomib therapy, but a biopsy specimen of the involved tissue did not reveal plasmacytoma. A control CT after three cycles of bortezomib also showed improvement in the soft tissue mass with a moderate callus formation and, as a result, moderately improved osteonecrosis ( fig. 1 b). In total, four cycles of bortezomib were given without bisphosphonates. The patient responded to bortezomib therapy with a significant decrease in M-protein. She is still on follow-up with no MM-related complaints, but has neuropathic pain due to bortezomib. The exact mechanism of bisphosphonate-induced jaw osteonecrosis has not been elucidated yet, however, the cumulative ischemic effect was suggested to be the causative event. It was reported that osteonecrosis induced by bisphosphonates did not improve following surgical resection or antibiotics [4, 5] . Bortezomib is the first proThe proteasome is an enzyme complex that degrades many targeted intracellular proteins. Inhibition of this enzyme complex affects the levels of various intracellular proteins that regulate the cell cycle, leading to a decrease in cell proliferation. Bortezomib is the first proteasome inhibitor to be used in cancer therapy, especially in multiple myeloma (MM) [1, 2] . However, we report a different effect of bortezomib in a patient with relapsed MM. A 58-year-old female patient was diagnosed as having IgG MM. She received three cycles of VAD (vincristine, adriamycin and dexamethasone) chemotherapy and high-dose melphalan with autologous peripheral blood stem cell support, followed by monthly zoledronic acid. One year after high-dose chemotherapy, she had a tooth extraction from the left jaw and sometime later, she was admitted with gum hyperplasia. Since no clinically associated disease was found to explain the gum hyperplasia, it was surgically resected. Histopathological examination of this material revealed normal histological findings. One year after the tooth extraction, a painful mass appeared on her left jaw and a few days later, an inflammatory material began to drain. Computerized tomography (CT) revealed osteitis and a widespread periosteal reaction in her mandible ( fig. 1 a). Biopsy of the involved bone disclosed osteonecrosis and a mixed inflammatory reaction, but there was no evidence of plasmacytoma. With a clinical suspicion of osteomyelitis, ampicillin/sulbactam therapy was given empirically and zoledronic acid was stopped. The fistula was successfully treated after 1 Received: July 4, 2007 Accepted after revision: September 6, 2007 Published online: November 9, 2007

Diagnosis of complex regional pain syndrome type I of the upper extremity: Role of dual energy X-ray absorptiometry and three-phase bone scintigraphy

Objective: The aim of the present study was to evaluate and compare the role of dual energy X-ray absorptiometry and three-phase bone scintigraphy in the diagnosis of complex regional pain syndrome type I of upper extremity. Methods: Five male and nineteen female patients diagnosed with complex regional pain syndrome type I (CRPSI) were included in this study. Three-phase bone scintigraphy (TPBS), bone mineral density (BMD) and bone mineral content (BMC) of wrist, metacarpophalangeal joint (MCP) and proximal interphalangeal (PIP) area in the affected and unaffected hands of patients were measured simultaneously using dual energy X-ray absorptiometry (DEXA). The time passed between the precipitating event and clinical onset of CRPSI was also recorded. Results: TPBS findings were in agreement with CRPSI diagnosis in 96% of the patients (23 of 24 patients). Periarticular BMD and BMC values in wrist, MCP, and PIP joints were statistically lower in affected hands than in unaffected hands for all three regions. Moreover, we found no correlation between BMD or BMC values with the sex, age, dominant hand, and the duration between the clinical onset of CRPSI and its precipitating event. Conclusion: The present study suggests that beside TPBS, a valuable tool in the early diagnosis of CRPSI, DEXA can also be used in the determination of early demineralization of bones in CRPSI patients. DEXA is an accurate, noninvasive, rapid, and safe device for quantitative assessment of unilateral bone loss caused by upper limb CRPSI.