The efficiency of mirror therapy in peripheral nerve injuries.

Objectives: The purpose of this study was to investigate the effectiveness of mirror therapy on pain, sensory, and functional development in addition to conventional rehabilitation and occupational practices in patients with a peripheral nerve injury in the hand. Patients and methods: Twenty-six patients with peripheral nerve injury in the hand were included in this randomized controlled study between November 2017 and May 2018. The patients were randomly assigned to the mirror group (n=14) and the control (n=12) group. Both groups received conventional therapy in our clinic for 45 min a day during weekdays for six consecutive weeks. The mirror group received an additional 10-15 min of visual mirror therapy. Visual Analog Scale (VAS), Duruöz Hand Index, Quick Disabilities of the Arm, Shoulder, and Hand, Jebsen hand function test, and Semmes-Weinstein monofilament test were used for the assessment of pain, hand function, and sensation of the patients at baseline and after treatment. The handgrip strength of the patients was measured with a dynamometer. Results: A total of 20 patients (17 males, 3 females; mean age 31.9±16.5, range 16 to 65 years) completed the study, with 10 in each group. Statistically significant improvement was detected in hand skill functions, such as page-turning (p=0.004), backgammon packing (p=0.023), and heavy object lifting (p=0.029) in the mirror group. A statistically significant decrease was found in total scores of VAS after treatment in both groups (p<0.05). Conclusion: The results imply that mirror therapy integrated with conventional rehabilitation may aid additional benefits on hand functions in peripheral nerve injury. These results demonstrate that mirror therapy can be used in addition to the rehabilitation program of patients with peripheral nerve injury.

The relation between elbow range of motion and patient satisfaction after open release of stiff elbow.

OBJECTIVE: The aim of this retrospective study was to find out whether a cut off value existed for elbow flexion and extension after open surgical release of elbow contracture that would correlate with subjective patient satisfaction. METHODS: The study enrolled 77 patients (53 males and 24 females with a mean age of 35.1 (18-77) years at the time of operation) with elbow contracture who attended regular follow-up appointments for more than 12 months. The mean follow up period was 44.2 months (12-186). The preoperative and postoperative modified MAYO elbow scores, objective parameters of increase in both flexion and extension end point measurements and improvement in total ROM were compared in order to determine the cut off degree of ROM in both flexion and extension that significantly correlated with patient satisfaction. RESULTS: Of the 77 participating patients, 26 patients had an extrinsic (33.8%) and 51 patients had an intrinsic elbow contracture (66.2%). Surgeries performed involved 40 cases of lateral release and 37 cases of both lateral and medial (progressive) release. The median preoperative total flexion-extension arch (ROM) was 45° (20°-65°). The median postoperative total flexion-extension arch (ROM) was 110° (97.5°-125°). The modified MAYO elbow score improved from 60 to 85 points postoperatively. The postoperative flexion cut off value was 115° for an excellent or good postoperative modified MAYO elbow score. CONCLUSION: Post-operative flexion cut off value was 115° and had a positive effect on the postoperative patient satisfaction. The cut off value for postoperative extension was 20° but it was not a significant variable on patient satisfaction as was the total increase in ROM. LEVEL OF SIGNIFICANCE: Level IV Therapeutic Study.

Proximal row carpectomy for Lichtman stage III Kienböck's disease.

OBJECTIVE: The purpose of this study was to investigate the objective and subjective outcomes of proximal row carpectomy (PRC) for stage III Kienböck's disease and determine if the physician's objective measurements correlate with the patients' subjective outcomes. METHODS: Twenty-four patients who underwent PRC for stage III Kienböck's disease with a follow-up period of more than 18 months were enrolled in the study. Clinical evaluation included preoperative and postoperative Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) questionnaire, postoperative Mayo wrist score, postoperative total joint range of motion (ROM), as well as grip and pinch strength measurements of the operated and normal side. Radiographic criteria such as carpal height ratio, subchondral cyst, and osteophyte formation were assessed during the follow-up period. Mean follow-up period was 41.7 months (range: 18-106 months). RESULTS: No wrists underwent total arthrodesis. Reflex sympathetic dystrophy was observed in 2 patients (8.3%). Postoperative ROM measurements, power grip, and pinch strength values significantly decreased in both stages (IIIA and IIIB) on the operated side compared to the normal side. In contrast, Q-DASH scores significantly increased in both stages compared to preoperative values. Average Mayo wrist score was 67.3 (range: 10-90). CONCLUSION: PRC is a well-tolerated procedure for stage III Kienböck's disease with certain complications. While subjective values improved significantly, there was no correlation between this improvement in subjective values and objective measurements. PRC was not able to restore motion postoperatively to that of the normal side, even though this feature did not affect postoperative subjective patient satisfaction.

Evaluation of contact characteristics of a patient-specific artificial dysplastic hip joint.

This study addresses the results of the experimental measurements for the contact surface areas and contact pressure distributions of a dysplastic hip joint. The hip joint consists of pelvis, proximal femur and artificial cartilages for both acetabulum and femoral head. The dysplastic hip joint is modeled in three dimensional (3D) form using the computerized tomography (CT) images obtained in vivo of an adult female patient. The modeled hip joint components are manufactured as a non-natural dysplastic hip joint using different materials and manufacturing processes. The dysplastic hip joint produced is subjected to compression forces experimentally to measure the contact surface area and contact pressure distributions between the femoral head and acetabulum using the pressure sensitive Fuji film. Different types of specific fixtures and molds are designed and manufactured to produce the dysplastic hip joint components and perform the experimental studies. The measured results using a non-natural dysplastic hip joint are compared with relevant results reported in current literature considering the peak and mean contact pressure values. Therefore, the obtained results showed that the non-natural dysplastic hip models can be generated and replaced to determine the contact characteristics for an elusive cadaveric model. In conclusion, the artificial models might be useful to understand the contact pressure distributions and potential changes in surface pressure contours and their effects on the stress distributions.

Mesenchymal stem cell application improves tendon healing via anti-apoptotic effect (Animal study).

OBJECTIVE: The aim of this study was to determine the effects of mesenchymal stem cell (MSC) application and the possible pathways of MSC's effects on tendon strength and healing after tendon repair. METHODS: The study included 40 Wistar albino rats. Mesenchymal stem cells were obtained from the femurs and tibias of 6 rats. Achilles tendons of the remaining 34 rats were cut and repaired with open surgical procedures. Rats were divided into 2 groups. Percutaneous MSCs were applied to the study group (n=17) and physiological serum only was applied to the control group (n=17) at the 4th week. Rats were sacrificed using the cervical dislocation method under ether anesthesia at the 12th week and samples were analyzed by histological and immunohistochemical methods. For biomechanical analysis, a traction force was applied at 10 mm/min and load to failure was recorded for each specimen in Newtons. RESULTS: Histologically, there was no significant difference between groups (p>0.05). In the immunohistochemical studies, MSCs were located more intensively at the repair zone. Apoptosis was minimally present in the study group and was clearly increased in the control group. Increase in tendon strength was significantly higher in the study group than in the control group at the 12th week (p<0.05). CONCLUSION: The application of MSCs to decrease re-ruptures has a positive effect on tendon strength, probably due to their anti-apoptotic effects. Mesenchymal stem cell application can be used percutaneously and is effective in clinical practice in the late stages of tendon healing.

Ultrasound-guided psoas compartment block and general anesthesia for arthroscopic knee surgery: a case report.

Anesthetizing the lumbar plexus at its origin facilitates a more "complete" psoas compartment block compared to peripheral approaches. It is usually performed using surface anatomical landmarks, and the site for local anesthetic injection is confirmed by observing quadriceps muscle contraction to peripheral nerve stimulation. Ultrasound may provide guidance alone or together with the aid of nerve stimulation during nerve blocks. We present a 48-year-old male patient, American Society of Anesthesiologists (ASA) physical status II, who refused spinal anesthesia, and underwent knee arthroscopy with ultrasound-guided psoas compartment block and general anesthesia. Following the standard monitoring and lateral decubitus positioning, the vertebral body, psoas, erector spinae, and quadratus lumborum muscles and hyperechoic nerve roots of the patient were visualized at the level of L4-5 with curvilinear ultrasound probe. The needle was inserted with ultrasound guidance, and correct tip position was confirmed with quadriceps contraction. Then, the mixture of 30 mL local anesthetic (10 mL 2% lidocaine and 20 ml 5% levobupivacaine) was injected at the estimated position of the lumbar plexus (junction of the posterior third and anterior two-thirds of the psoas muscle). He also received general anesthesia for the surgery. Anesthesia and surgical procedures were completed successfully without any additional anesthetic/analgesic requirement or complication. The postoperative period was pain-free both at rest and during mobilization for 24 hours. This case report shows that ultrasound-guided psoas compartment block is feasible and efficient for peri- and postoperative analgesia during knee arthroscopy.

Bilateral carpal tunnel syndrome in a 9-year-old boy with acromicric dysplasia.

Acromicric dysplasia is a skeletal dysplasia that is characterized by short stature, short hands and feet, typical facial dysmorphism, normal mental development, and characteristic hand radiology. Carpal tunnel syndrome may be seen in adults with acromicric dysplasia; however, to the authors' knowledge, it has not been reported in pediatric patients. This article describes a 9-year old boy with bilateral carpal tunnel syndrome and acromicric dysplasia treated operatively. No recurrences occurred during 1 year of postoperative follow-up.Carpal tunnel syndrome is a rare disease in childhood. The etiologic factors of carpal tunnel syndrome include trauma (especially distal radius epiphysealis), overuse, genetic or metabolic disorders, space-occupying lesions in the carpal tunnel, hemophilia, congenital anomalies, adverse effect of growth hormone replacement therapy, and idiopathic carpal tunnel syndrome. Acromicric dysplasia should be considered in the etiology of childhood carpal tunnel syndrome.The surgical outcome of carpal tunnel syndrome is good with early diagnosis and treatment. However, in the case of skeletal dysplasia, the diagnosis of carpal tunnel syndrome may be delayed due to anomalies of the hand and due to the child's difficulty in expressing symptoms. Because of the delay in diagnosis of carpal tunnel syndrome in patients with skeletal dysplasia, the treatment outcomes may not be promising. Electrophysiologic studies should be performed early when the clinical signs are positive.

Boyd amputation in adults.

BACKGROUND: Foot ulcerations resulting in amputation are one of the most devastating consequences of diabetes mellitus and peripheral arterial disease. In foot amputations, Boyd amputation has been even less accepted than Syme amputation due to its dependence on calcaneotibial osseous union in adults. METHODS: Fifteen Boyd amputations were performed for 14 adults. The indications for amputation were diabetic ulceration of the foot in eight patients, ischemic disease of the lower extremity in four and salvage of the deformed foot due to peripheral neuropathy in one patient. One patient with scleroderma had bilateral amputations due to digital ischemic necrosis. RESULTS: Complete wound healing was documented in seven feet of six patients. Further revisions to a more proximal amputation level were required in seven patients. CONCLUSION: Despite the high failure rate, we believe Boyd amputation is still a good option in some patients to try to preserve length.

Deformity correction by Ilizarov distraction osteogenesis after distal radius physeal arrest.

OBJECTIVE: The aim of this study was to evaluate the results of osteotomy and distraction osteogenesis using Ilizarov circular external fixator to treat radial shortening and severe wrist deformity due to neglected post-traumatic distal radius physeal arrest. METHODS: The study retrospectively reviewed 4 patients (4 males; average age: 16 years; range: 14 to 19 years) who underwent osteotomy and distraction osteogenesis to treat radial shortening and severe wrist deformity due to neglected distal radius physeal arrest. Mean interval between trauma and surgical intervention was 8 (range: 4 to 12) years and mean follow-up time was 83 (range: 40 to 126) months. Patients were evaluated with radiographic measurements (shortening and lengthening ratio, radioulnar joint leveling, distal radioulnar joint congruency), objective functional measurements (grip and pinch strength, range of motion measurements [ROM]) and subjective functional measurements (Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire and Mayo wrist score). Statistical analysis was made using the Mann-Whitney U non-parametric test. RESULTS: Radiographic measurements were obtained preoperatively and at the final follow-up. The mean shortening ratio of the radius was 14.6% (range: 9.3% to 18.7%) and mean lengthening ratio was 15.9% (range: 13.2% to 18.3%). Normal distal radioulnar joint leveling and distal radioulnar congruency resembling a joint was established in all but one patient with four millimeters of ulna plus deformity. According to the Mann-Whitney U non-parametric test, there was no statistical difference in grip and pinch power, ROM on flexion/extension, and ulnar/radial deviation axis between the operated and non-operated sides. There was statistically significant pronation/supination restriction between the operated and non-operated sides (p<0.04). Mean DASH score was 2.07 (range: 0.0 to 8.3) and the mean Mayo wrist score was 89 (range: 75 to 100) points. According to the Mayo wrist score, results were excellent in one patient, good in two patients, and satisfactory in one patient. CONCLUSION: The use of distal metaphyseal osteotomy and Ilizarov distraction osteogenesis is a viable treatment method for neglected physeal fractures of the distal radius as it establishes acceptable deformity correction and a functional wrist joint.

Isolated pedicle screw instrumented correction for the treatment of thoracic congenital scoliosis.

STUDY DESIGN: Retrospective study. OBJECTIVE: To evaluate the radiologic results of fusion with segmental pedicle screw fixation in neglected thoracic congenital curves with a mean follow-up of 51.3 months (range: 24 to 108 mo). SUMMARY OF BACKGROUND DATA: Segmental pedicle screw fixation has been shown to be effective both in correcting and controlling the idiopathic spinal deformities. However, the choice of treatment modality is more controversial in neglected thoracic congenital curves of the aged. METHODS: Fourteen patients with thoracic congenital curves treated by segmental pedicle screw fixation and fusion were analyzed. The average age of the patients was 14.9 years (range: 10 to 25 y) at surgery. Deformity correction was achieved by compression of the convex deformity side with resection of apical 3 ribs. Radiologic analyses of coronal and sagittal plane included Cobb angles of the major compensatory curves, apical vertebrae translation, and sagittal Cobb angles, respectively. RESULTS: In the coronal plane, the preoperative mean major curve Cobb angle of 52.3 degree (range: 32.6 to 66.7 degrees) was corrected to 25.3 degree (range: 7.2 to 44.8 degree) and the mean compensatory curve Cobb angle of 23.6 degree (range: 10.3 to 34.8 degrees) was corrected to 15.9 degree (range: 5.7 to 30.6 degrees). The mean translation of apical vertebrae was 28.8 mm (range: 4.7 to 53.6 mm) before surgery and 15.5 mm (range: 2.4 to 41.3 mm) after surgery. In the sagittal plane, the mean preoperative and postoperative sagittal T5 to T12 angles were 34.8 degree (range: 16.5 to 44.7 degrees) and 27.3 degree (range: 10.4 to 43.5 degrees), respectively. The mean preoperative and postoperative sagittal T12 to S1 angles were 47.2 degree (range: 23.4 to 65.1 degrees) and 41.3 degree (range: 23.8 to 62.7 degrees), respectively. CONCLUSION: In the neglected thoracic congenital deformities of the aged, with posterior pedicle instrumented fusion, an acceptable correction can be achieved with relatively low morbidity.

An unusual type of lateral compression injury of the pelvis tilt fracture with anterior displacement.

Tilt fracture is the most unusual variant of pelvic lateral compression injury. The major problem was reported to be protrusion of the pubic ramus into the perineum by posterior-inferior displacement of the fragment. Tilt fragment with anterior and inferior displacement has not been reported in English speaking literature to our knowledge. Anterior tilt fragment can cause significant morbidity in terms of vascular injury, pelvic stability and acetabular fracture.

Evaluation of thoracic pedicle screw placement in adolescent idiopathic scoliosis.

Pedicle screw fixation is a challenging procedure in thoracic spine, as inadvertently misplaced screws have high risk of complications. The accuracy of pedicle screws is typically defined as the screws axis being fully contained within the cortices of the pedicle. One hundred and eighty-five thoracic pedicle screws in 19 patients that were drawn from a total of 1.797 screws in 148 scoliosis patients being suspicious of medial and lateral malpositioning were investigated, retrospectively. Screw containment and the rate of misplacement were determined by postoperative axial CT sections. Medial screw malposition was measured between medial pedicle wall and medial margin of the pedicle screw. The distance between lateral margin of the pedicle screw and lateral vertebral corpus was measured in lateral malpositions. A screw that violated medially greater than 2 mm, while lateral violation greater than 6 mm was rated as an "unacceptable screw". The malpositions were medial in 20 (10.8%) and lateral in 34 (18.3%) screws. Medially, nine screws were rated as acceptable. Of the 29 acceptable lateral misplacement, 13 showed significant risk; five to aorta, six to pleura, one to azygos vein and one to trachea. The acceptability of medial pedicle breach may change in each level with different canal width and a different amount of cord shift. In lateral acceptable malpositions, the aorta is always at a risk by concave-sided screws. This CT-based study demonstrated that T4-T9 concave segments have a smaller safe zone with respect to both cord-aorta injury in medial and lateral malpositions. In these segments, screws should be accurate and screw malposition is to be unacceptable.

Juvenile idiopathic scoliosis treated with posterior arthrodesis and segmental pedicle screw instrumentation before the age of 9 years: a 5-year follow-up.

STUDY DESIGN: Retrospective study. OBJECTIVE: To evaluate the radiological results of fusion with segmental pedicle screw fixation in juvenile idiopathic scoliosis with a minimum 5-year follow-up. SUMMARY OF BACKGROUND DATA: Progression of spinal deformity after posterior instrumentation and fusion in immature patients has been reported by several authors. Segmental pedicle screw fixation has been shown to be effective in controlling both coronal and sagittal plane deformities. However, there is no long term study of fusion with segmental pedicle screw fixation in these group of patients. METHODS: Seven patients with juvenile idiopathic scoliosis treated by segmental pedicle screw fixation and fusion were analyzed. The average age of the patients was 7.4 years (range 5-9 years) at the time of the operation. All the patients were followed up 5 years or more (range 5-8 years) and were all Risser V at the most recent follow up. Three dimensional reconstruction of the radiographs was obtained and 3DStudio Max software was used for combining, evaluating and modifying the technical data derived from both 2d and 3d scan data. RESULTS: The preoperative thoracic curve of 56 +/- 15 degrees was corrected to 24 +/- 17 degrees (57% correction) at the latest follow-up. The lumbar curve of 43 +/- 14 degrees was corrected to 23 +/- 6 degrees (46% correction) at the latest follow-up. The preoperative thoracic kyphosis of 37 +/- 13 degrees and the lumbar lordosis of 33 +/- 13 degrees were changed to 27 +/- 13 degrees and 42 +/- 21 degrees , respectively at the latest follow-up. None of the patients showed coronal decompensation at the latest follow-up. Four patients had no evidence of crankshaft phenomenon. In two patients slight increase in Cobb angle at the instrumented segments with a significant increase in AVR suggesting crankshaft phenomenon was seen. One patient had a curve increase in both instrumented and non instrumented segments due to incorrect strategy. CONCLUSION: In juvenile idiopathic curves of Risser 0 patients with open triradiate cartilages, routine combined anterior fusion to prevent crankshaft may not be warranted by posterior segmental pedicle screw instrumentation.

MR spectroscopy findings in tuberculous spondylitis; comparison with Modic type-I end-plate changes and metastatic vertebral disease.

PURPOSE: To define single-voxel proton magnetic resonance spectroscopy (MRS) findings of vertebral tuberculous spondylitis (TBS), Modic type-I end-plate changes (MTEC) and metastatic vertebral disease (MVD). MATERIALS AND METHODS: Fifteen patients with TBS, 15 with MTEC and 15 with MVD were included. MRS from the diseased vertebral body as well as normal vertebral body was examined. Water and lipid peak were measured, water-to-lipid ratio (WLR) and for each patient lesion water index (LWI, the ratio of WLRs from diseased to normal vertebrae) were calculated. RESULTS: The mean WLR of normal and pathologic vertebra was 0.91 and 7.13 in TBS group, 0.84 and 3.49 in MTEC group and 0.65 and 3.17 in MVD group, respectively. The mean LWI was 10.68 in TBS, 6.04 in MTEC and 6.42 MVD groups. Statistical significance was not achieved between the WLR and LWI of the TBS, MTEC nor MVD group (p>0.05). CONCLUSION: The mean values of WLR and LWI in the TBS group are relatively higher than MTEC and MVD groups, with the difference being statistically insignificant.

Effect of insertional temperature on the pullout strength of pedicle screws inserted into thoracic vertebrae: an in vitro calf study.

STUDY DESIGN: The axial pullout strength of pedicle screws that were at different temperatures when inserted was compared in calf vertebrae. OBJECTIVE: To determine if insertional temperature of the screw itself affects pullout strength. SUMMARY OF BACKGROUND DATA: Fixation stability of pedicle screws depend on several factors. The development of alternate insertion techniques and screw designs were used to improve the stability. Polymethylmethacrylate and calcium sulfate augmentation have been shown to be viable options for improving fixation; but have the potential disadvantages. METHODS: Three cadaveric thoracic calf spines were instrumented between T1-T10 bilaterally with one type of pedicle screws stored at different insertional temperatures. The axial pullout tests were performed at cross head speed of 5 mm/min. Pullout loads and displacement were recorded at 1/20 seconds intervals until failure occurred. RESULTS: The highest pullout force was obtained with the screws inserted at 4 degrees C. These screws had a 19% increase in pullout strength compared with the screws inserted at 24 degrees C. The highest force/torque proportion was gained in the same group as 0.30 kn/Nm. CONCLUSION: The technique showed increased pullout force with the screws inserted at 4 degrees C. Using pedicle screws stored at 4 degrees C before instrumentation, seems reasonable in an attempt to obtain a better bone-screw interface.

Placement of pedicle screws in thoracic idiopathic scoliosis: a magnetic resonance imaging analysis of screw placement relative to structures at risk.

In posterior pedicle screw instrumentation of thoracic idiopathic scoliosis, screw malposition might cause significant morbidity in terms of possible pleural, spinal cord, and aorta injury. Preoperative axial magnetic resonance images (MRI) in 12 consecutive patients with right thoracic adolescent scoliosis, all with King type 3 curves, were analyzed in order to evaluate the relationship between the inserted pedicle screw position to pleura, spinal cord, aorta. Axial vertebral images for each thoracic level were scanned and the simulation of pedicle screw insertion was performed using a digital measurement programme. The angular contact value for each parameter regarding the pleura and spinal cord was measured on both sides of the curve. The aorta-vertebral distance was also measured. Aorta-vertebral distance was found to be decreasing gradually from the cephalad to the caudad with the shortest distance being measured at T12 with a mean of 1.2 mm. Concave-sided screws on T5-T9 and convex-sided screws on T2-T3 had the greatest risk to spinal cord injury. Pleural injury is most likely on T4-T9 segments by the convex side screws. T4-T8 screws on the concave side and T11-T12 screws on the convex side may pose risk to the aorta. This MRI-based study demonstrated that in pedicle instrumentation of thoracic levels, every segment deserves special consideration, where computer scanning might be mandatory in immature spine and in patients with severe deformity.

Chronic post-traumatic radial head dislocation associated with dissociation of distal radio-ulnar joint: a case report.

We present an unusual case of an isolated interosseous membrane disruption of the forearm without any fracture pattern. Dislocation of both radial head and distal radio-ulnar joint was presented. Open reduction of the radial head with radial neck shortening osteotomy was performed.

Pedicle morphology of the thoracic spine in preadolescent idiopathic scoliosis: magnetic resonance supported analysis.

Although several studies have been reported on the adult vertebral pedicle morphology, little is known about immature thoracic pedicles in patients with idiopathic scoliosis. A total of 310 pedicles (155 vertebrae) from T1 to T12 in 10-14 years age group were analyzed with the use of magnetic resonance imaging and digital measurement program in 13 patients with right-sided thoracic idiopathic scoliosis. Each pedicle was measured in the axial and sagittal planes including transverse and sagittal pedicle width and angles, chord length, interpedicular distance and epidural space width on convex and concave sides of the curve. The smallest transverse pedicle widths were in the periapical region and the largest were in the caudal region. No statistically significant difference in transverse pedicle widths was detected between the convex and concave sides. The transverse pedicle angle measured 15.56 degrees at T1 and decreased to 6.32 degrees at T12. Chord length increased gradually from the cephalad part of the thoracic spine to the caudad part as the shortest length was seen at T1 convex level with a mean of 30.45 mm and the largest length was seen at T12 concave level with a mean of 41.73 mm. The width of epidural space on the concave side was significantly smaller than that on the convex side in most levels of the curve. Based on the anatomic measurements, it may be reasonable to consider thoracic pedicle screws in preadolescent idiopathic scoliosis.