The effects of long-term low-dose cyclosporin A treatment on muscles and tendons: an experimental study.

BACKGROUND: Limited studies report that patients receiving immunosuppressive therapy, including cyclosporin A (CsA), face muscle and/or tendon pathologies. The current study aimed (i) to investigate if CsA cause changes in the microscopic structure of striated muscle tissues and tendons after long-term low-dose therapy and (ii) to examine if the vehicle of CsA, Cremophor EL, or steroid administration might cause additional effects. METHODS: Twenty-four adult female Sprague-Dawley rats weighing 230-300 g were divided at random into four groups. Group 1 served as the control. Groups 2-4 received CsA intraperitoneally for 2.5 months: Group 2 received the oral form of CsA, Group 3 received the intravenous form of CsA, which contains Cremophor EL, and Group 4 received the intravenous form of CsA and prednisolone. Samples from the Achilles tendons and triceps surae muscles were examined at light microscope level. RESULTS: Focal necrotic areas, enlargement of connective tissue and increase in mononuclear cells were clear on muscles in the experimental groups. No morphologic effects were observed on tendons. CONCLUSION: Long-term low-dose CsA therapy causes focal microscopic changes in muscles but not in tendons. No additional effects were demonstrated with Cremophor EL or steroids. It should be noted that muscle tissue damage after trauma or surgeries in patients receiving CsA might be more dramatic due to the pathologic changes already caused by CsA, as supported by several case reports.

Open versus minimal invasive repair with Achillon device.

BACKGROUND: We prospectively analyzed and compared the functional and clinical results of patients with standard open and minimally invasive repair with the Achillon suture system at mid-term followup. MATERIALS AND METHODS: From February 2004 to May 2007, 40 consecutive patients were operated for the treatment of acute Achilles tendon rupture with two different methods. None of the cases required adjunctive procedures like plantaris, flexor hallucis longus or gastrocnemius augmentation (Lindholm, Bosworth) to allow for acceptable end to end apposition. The patients were divided equally into two groups. In Group 1, only Krakow end-to-end suturing technique and in Group 2, Minimal invasive repair with Achillon suture system (Integra Life Sciences Corporation, Plainsboro, NJ) was used respectively. The average age of the patients was 40 years. Patients in study groups were followed up at mean of 22.4 (range, 10 to 48) months after surgery. At the end of the followup time, functional outcome scores and complications were evaluated. RESULTS: The AOFAS hindfoot clinical outcome scores were 98.7 in Group 1, 96.8 in Group 2. Although there was a numerical increase in AOFAS Scores in Group 1, there was no significant difference. The surgical outcome concerning local tenderness, skin adhesions, scar and tendon thickness was better in Group 2 than in Group 1 with statistical significance. CONCLUSION: Although functional outcomes of both treatment groups were the same, minimally invasive repair with the Achillon suture system provided safe, reliable and practical treatment with low risk of complications in the treatment of acute Achilles tendon ruptures.

Capitellar cartilage injuries concomitant with radial head fractures.

PURPOSE: To evaluate the incidence and types of capitellar cartilage injuries associated with higher-grade radial head fractures. METHODS: Fifty-one consecutive patients with operatively treated, unstable, displaced Mason type II to III radial head fractures were identified. Ten of 51 patients had capitellar cartilage injuries concomitant with these fractures. All cartilage injuries were identified at the time of surgery except in 1 patient whose injury was determined via computed tomography. There were 8 men and 2 women with an average age of 33 years (range, 24-39 years). Lesions were seen with direct inspection and recorded by location, size, and thickness. RESULTS: The incidence of capitellar chondral lesions concomitant with operatively treated Mason type II to III radial head fractures appeared in 10 of 51 patients. The average size was 5 x 5 mm (range, 2 x 2 mm to 10 x 10 mm). Four patients had Mason type II and 6 had Mason type III radial head fractures. The average surface of the cartilage injury was 6 x 7 mm (range, 3 x 6 mm to 10 x 10 mm) for Mason type II fractures and 4 x 4 mm (range, 2 x 2 mm to 5 x 10 mm) for Mason type III fractures. Two Mason type III fractures had full-thickness cartilage lesions, and 4 Mason type III fractures had partial-thickness cartilage lesions. Two Mason type II fractures had full-thickness cartilage lesions and the other 2 had partial-thickness cartilage lesions. CONCLUSIONS: Capitellar cartilage lesions frequently occurred concomitantly with higher-grade radial head fractures. The incidence of these lesions increased with greater severity of radial head fractures. Low-grade radial head fractures created higher-grade cartilage lesions as the intact radial head can cause more damage to the capitellum. Careful evaluation of the joint should be performed for these subtle injuries. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

A positioning technique for closed intramedullar nailing of tibia fractures.

BACKGROUND: We described a method of positioning the patient on the standard operation table that enables manual traction and equipment that is available in almost all operating theaters and compared it with regular positioning technique. METHODS: Eighty two patients with unstable unilateral tibia fractures were evaluated and treated in the author's clinic between July 2002 and June 2006. The average age of the patients was 40.6 (29-65) years. The surgical indications included uncomplicated closed fractures, fractures in patients with multiple injuries, and inability to maintain a satisfactory closed reduction. Forty-two fractures that were operated with the new technique and meet these criteria's were included in the study. All operations were performed on normal operation tables. RESULTS: There was not any case of failure related with the nailing and the presented positioning technique. Intraoperative reduction was achieved with closed method in all patients. In 10 patients, satisfactory reduction was achieved with the help of polar screws in 2 patients and cable system in 8 patients. Anatomic reduction was obtained in the rest of 32 patients. There were no cases of compartment syndrome diagnosed postoperatively in both injured and uninjured side. There were also no neurologic complications and postoperative infection formation related to surgery. CONCLUSION: The advantages of this technique is that, it allows precise reduction, control of rotation, and easy imaging access, without increasing operating or screening time and complication.

Incidence of chondral lesions of talar dome in ankle fracture types.

BACKGROUND: Although the surgical treatment of ankle fractures is well known, a paucity of literature exists correlating chondral lesions with ankle fracture types. MATERIALS AND METHODS: This study is a retrospective review of patients with absence or presence of chondral lesions that underwent arthroscopically assisted open reduction and internal fixation between June 2002 and April 2005. There were 38 female and 48 male patients (mean age, 41.4 years; mean followup, 33.9 months), and all had an Ankle-Hindfoot Scale score. The relationship between fracture types and presence of lesions was evaluated. RESULTS: Four of 27 fractures with chondral lesions consisted of the bimalleolar type, 6 of 15 fractures with chondral lesions consisted of the trimalleolar type, and 14 of 20 distal fibula fractures had chondral lesions. There was significant greater incidence of chondral lesions associated with distal fibula fractures. The mean AOFAS score was 95.6 among all fractures. CONCLUSION: There is clear evidence that despite anatomic reduction, postoperative results of ankle fracture repair are not free of complications. We believe inspection of the talar dome should be routinely considered in the surgical repair ankle fractures.

Fibro-osseous pseudotumor of the digits: a rare tumor in an unusual location.

Fibro-osseous pseudotumor of the digits (FOPT) is a rare benign lesion of the hand. When FOPT originates in an unusual anatomic region (other than the digits), it can imitate a malignant neoplasm, and consequently surgical treatment can be improper. This report describes a case of FOPT that developed in an unusual anatomic region: the first dorsal-extensor compartment of the wrist.

Open reduction and internal fixation of Mason type III radial head fractures with and without an associated elbow dislocation.

PURPOSE: The purpose of this study was to evaluate the treatment of patients with Mason type III radial head fracture with and without elbow dislocation by open reduction with internal fixation, collateral ligament repair, and early mobilization. An additional purpose was to investigate whether there is any effect of elbow dislocation on the severity and functional outcome. METHODS: Twenty-five patients were treated with open reduction with internal fixation using low-profile miniplate and screws for comminuted fracture of the radial head. Eighteen fractures were Mason type III, and 7 fractures were Mason type III with elbow dislocation. There were 5 women and 20 men with a mean age of 34 years. The mean follow-up time was 27 months. Patients were reviewed for functional ability, physical examination, and radiographic assessment. RESULTS: The mean functional index in Mason type III fracture and Mason type III fracture with elbow dislocation was 87 for both groups. The mean range of motion at the elbow joint was calculated as 5 degrees extension to 136 degrees flexion for Mason type III and 7 degrees extension to 133 degrees flexion for Mason type III with elbow dislocation. The mean pronation and supination for all patients were 74 degrees and 67 degrees , respectively. CONCLUSIONS: Selected Mason III radial head fractures and fracture dislocations could be stabilized satisfactorily with internal fixation. Meticulous surgical technique, combined with rigid internal fixation, can allow early motion of the forearm and elbow after fixation of Mason type III radial head fractures with and without elbow dislocation and ligamentous injury. We believe there is still a role for prosthetic replacement in comminuted Mason III radial head fractures that cannot reliably be treated with open reduction and internal fixation. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

End-to-end versus augmented repair in the treatment of acute Achilles tendon ruptures.

We prospectively analyzed the functional and clinical results of patients who underwent a single end-to-end suture and an augmented tendon repair with plantaris tendon at middle-term follow-up. From January 2003 to May 2005, 30 consecutive patients were operated on for the treatment of acute Achilles' tendon rupture by means of 2 different methods. No cases required adjunctive procedures to allow for acceptable end-to-end apposition. All ruptures were acute and repairable. The patients were divided into 2 groups. In group 1, augmentation with plantaris tendon was performed in addition to the Krakow end-to-end suturing technique in 16 patients, and in group 2, only the Krakow end-to-end suturing technique was used in 14 patients. The average age of the patients was 40.6 years. Patients in the study groups were followed up at a mean of 17.8 months after surgery. At the end of the follow-up, functional and subjective outcome scores were evaluated. The American Orthopaedic Foot and Ankle Society hindfoot clinical outcome scores were 96.7 in group 1 and 98.8 in group 2. Although there was a numerical increase in group 2, no significant difference was determined between the 2 study groups statistically. The surgical outcome concerning local tenderness, skin adhesion scar, and tendon thickness was better in group 2 than in group 1 without a statistical significance. Although functional outcomes of both treatment groups were the same, the end-to-end suturing technique provided a safer and more reliable treatment with a low risk of complications in the treatment of acute Achilles' tendon ruptures compared with the plantaris tendon augmentation technique.

[Surgical treatment of unstable fracture-dislocations of the proximal interphalangeal joint]. / Proksimal interfalangeal eklemin instabil kirikli çikiklarinin cerrahi tedavisi.

OBJECTIVES: The purpose of this study was to evaluate the results of surgical treatment of unstable fracture-dislocations of the proximal interphalangeal (PIP) joint. METHODS: The study included 13 patients (12 males, 1 female; mean age 31 years, range 23 to 48 years) with dorsal fracture-dislocations of the PIP joint. Six patients were treated with open reduction and internal fixation using 1.2-mm titanium screws within the first week of injury. In seven patients with late presentation, time from injury to surgery ranged from 21 to 56 days (mean 37 days). Of these, one was treated with mini screws, four with bone anchors, and two with mini screws and bone anchors. The mean follow-up period was 21.5 months (range 12 to 48 months). RESULTS: Radiographic union was achieved in all the patients. The range of motion of the PIP joint was 73.4 degrees (range 50 degrees -90 degrees ) on the affected side, and 91.9 degrees (range 90 degrees -100 degrees ) on the normal side. Patients presenting early and late had significantly different range of motion of the injured fingers (84.1 degrees and 64.2 degrees , respectively; p<0.05). The mean flexion contracture of the injured fingers was 13 degrees (range 0 degrees -30 degrees ). There was no significant difference with regard to the PIP joint motion between patients treated with mini screws and soft tissue reconstruction. The mean grip strengths were 45.7 kg and 49.3 kg on the affected and normal sides, respectively. Four patients had degenerative signs in the PIP joint and one patient with late-presentation developed subluxation. Four patients complained of limitation of mild degree at work or in daily activities. CONCLUSION: Treatment of fracture-dislocations of the PIP joint yields successful results with mini screws in early cases or appropriate injuries, and with soft tissue reconstruction with or without mini screws in late-presenting patients or unfavorable injuries.

Chondromyxoid fibroma involving the entire metacarpal: a case report.

The occurrence of chondromyxoid fibroma in the hand is rare. We report a case of chondromyxoid fibroma involving the whole fourth metacarpal that was treated by curettage and cancellous bone allograft.

An evaluation of the underlying causes of fall-induced hip fractures in elderly persons.

BACKGROUND: Falls are the major cause of hip fractures in elderly patients. The aim of this prospective study was to investigate the underlying causes of fall-induced hip fractures in the elderly. METHODS: The study included 32 patients (18 males, 14 females; mean age 78 years; range 57 to 95 years) who had proximal femoral fractures following an unexpected and sudden fall from about a meter height at a moment of lying, sitting, or standing position. Underlying causes of falls were sought, including previous falls, stroke, polyneuropathy, motion disorders, dementia, vision problems, fainting, vestibular pathologies, and cardiac diseases. RESULTS: Eight patients (25%) had a history of previous falls and 12 patients (37.5%) had a history of stroke. Polyneuropathy, Parkinson's Disease, and dementia were diagnosed in eight (25%), three (9.4%), and five (15.6%) patients, respectively. Twenty-one patients (65.6%) had neurologic diseases, 11 patients (34.4%) had cataract or other vision problems, eight patients (25%) had osteoarthritis and rheumatoid arthritis, 10 patients (31.3%) had vestibular pathologies, and 17 patients (53.1%) had cardiac diseases such as heart failure, orthostatic hypotension, ischemic heart disease, and arrhythmia. CONCLUSION: In order to prevent recurrent falls, risk factors associated with falls should be determined and preventive treatment and measures should be put into practice in elderly patients who have fall-induced injuries.

Clinical evaluation of ulnar nerve repair at wrist level.

INTRODUCTION: In this study, the results of ulnar nerve repair were analyzed. The relation between the functional outcome scores and clinical findings were investigated to find out whether any clinical finding could be predictive of the outcome. MATERIALS AND METHODS: Seventeen patients who underwent ulnar nerve repair formed the study group. Average follow-up lasted 45.5 months (range 39-48 months), and average age of the study group was 31.7 years (range 26-42 years). The same operative technique was applied to all patients by one of the authors (HG). Follow-up checks were done at 3, 6, and 12 months postoperatively. The patients who did not attend the last follow-up were excluded from the study group. The Seddon classification was used as the functional scoring system. Wound healing, Tinel sign, interosseous atrophy, atrophy of the first web space, clawing, and protective sensation were the clinical findings examined at the follow-ups. Wound healing was classified as either normal scar formation or hypertrophic scar-keloid (HsC) formation. RESULTS: Good results in 4 and fair results in 13 were obtained according to the Seddon classification. Statistically, there was no difference between the clinical findings at the 3, 6, and 12 month follow-ups. CONCLUSION: Presence of HsC and clawing can be regarded as a predictive sign for fair results in nerve repairs.