The longer pull-out suture as a transmission suture for early active motion of repaired flexor tendon at the proximal zone-2.

OBJECTIVES: The purpose of the current study was to clinically evaluate the technique of longer pull-out suture as a transmission suture for early active motion after flexor tendon repair in the proximal zone-2. METHOD: Eleven patients (eight adult male, two adult female and one child) with 19 proximal zone II flexor tendon lacerations were included. Mean age was 35 years. The patients were encouraged to perform active mobilization of the injured digits by themselves with full range of flexion from the first postoperative day. The pull-out suture was removed at the 8-10 weeks after the operation. RESULTS: The mean follow-up was 39 months. The procedure was well tolerated by all of the patients. A patient of whom pull-out suture was traumatized and loosened at 6th week showed fair result. Two other patients with a history of blunt trauma were also found to have fair results. Overall 16 of the 19 digits were evaluated as excellent or good by the Strickland criteria. CONCLUSION: The results of this method show that the longer pull-out suture technique as a transmission suture followed by early active mobilization is safe, has a low re-rupture rate and is easy to perform for proximal zone-2 flexor tendon injuries.

The effect of intraarticular combinations of tramadol and ropivacaine with ketamine on postoperative pain after arthroscopic meniscectomy.

INTRODUCTION: The purpose of this prospective randomized study was to evaluate the effects of intraarticular combinations of tramadol and ropivacaine with ketamine in postoperative pain control of patients undergoing arthroscopic meniscectomy. MATERIALS AND METHODS: We randomly divided 80 patients into four groups to receive intraarticular 50 mg tramadol (Group T), 50 mg tramadol with 0.5 mg kg(-1) ketamine (Group TK), 75 mg ropivacaine (Group R), 75 mg ropivacaine with 0.5 mg kg(-1) ketamine (Group RK) in 20 ml normal saline at the end of surgery. Postoperative analgesia was provided with patient-controlled analgesia with morphine. Postoperative pain scores, total morphine consumption amount and side effects were recorded at intervals of 0, 1, 2, 4, 8, 12 and 24 h after the operation. RESULTS: Pain scores were higher in Group T when compared with Group R and Group RK at second and fourth hours, also compared with Group RK at zeroth, first, second, fourth and eighth hours. Total morphine consumption amount was found to be higher in Group T when compared to Group TK at eighth and twelfth hours and Group RK at eighth hours (P < 0.05). Total morphine consumption was lowest in Group TK (P < 0.05). There were no significant differences among the study groups regarding side effects. CONCLUSIONS: Administration of intraarticular tramadol-ketamine combination was found to be more effective in decreasing postoperative daily analgesic consumption.

The fate of patellar tendon and infrapatellar fat pad after arthroscopy via central portal.

Central patellar (CP) portal is an accessory portal in arthroscopic knee surgery, which generally is considered to be safe. In this cross sectional study, we aimed to delineate the clinical and radiological outcome of patellar tendon (PT) and Hoffa's fat pad after the use of this approach. From our hospital records, patients who underwent arthroscopy via CP portal were identified and were invited for the study. There were16 men and 4 women with a mean age of 32 years. Mean follow-up time was 28 months. Meniscectomy had been performed for irreparable bucket-handle type medial meniscal tears in all patients. At the latest follow-up, no patients had anterior knee pain and physical examination was normal. Mean PT thickness of operated knees measured with Ultrasonography was 5.63+/-1.56, while it was 3.76+/-0.46 mm in contralateral knees and the difference was significant. Contour irregularity of PT and focal hypoechoic areas were found in 17 patients, two of which also had hyperechogenic calcification focuses. Abnormal signal intensity of PT was also found in 17 patients with Magnetic Resonance Imaging (MRI). Eleven of these had decreased signal intensity within the tendon which was interpreted as fibrosis. In six patients, increased signal intensity, radiologically similar to chronic tendinitis, was detected. Four patients had decreased signal intensity in the Hoffa's fat pad. Local fibrous tissues in patellar tendon might cause weakness in the tendon. This study showed that although CP portal did not cause any clinical problems in a low demand group of patients, it leads to a significant radiological sequela in the tendon, biomechanical significance of which needs to be clarified.

[In which period of skeletal muscle ischemia-reperfusion injury is local hypothermia more effective?]. / Iskelet kasi iskemi-reperfüzyon hasarinin hangi evresinde lokal soguk uygulamasi daha etkilidir?

OBJECTIVES: We investigated the potential beneficial effects of local hypothermia applied during different periods of ischemia-reperfusion injury in a rat model. METHODS: An isolated gracilis muscle model of ischemia-reperfusion injury was used consisting of four groups, each with six rats. Ischemic injury was induced by clamping the femoral artery for six hours. Local hypothermia at 10 degrees C was applied during only ischemia (IH), during reperfusion (RH) for four hours, and during both ischemia and reperfusion (IRH). The control group remained untreated. After 24 hours of perfusion, the rats were sacrificed and the gracilis muscles were removed to determine muscle edema (wet-to-dry weight ratio), polymorphonuclear leukocytes (PMNL), and the percentage of necrosis. RESULTS: Compared to the control group (193.7 +/-38.9), the PMNL count was significantly lower in the IH, RH, and IRH groups (111.5+/-36.2, p<0.004; 82+/-18.6, p<0.002; 54.5+/-21.8, p<0.002, respectively). The only significant difference in the PMNL count was between the IH and IRH groups (p<0.004). In all the hypothermia groups, the percentage of necrosis was found significantly less than that of the control group (22.5+/-5.2% vs 11.7+/-5.2% in IH, p<0.004; 10.8+/-3.8% in RH, p<0.004; 6.7+/-2.6% in IRH, p<0.002).Similarly, muscle edema was significantly decreased in the study groups (control, 2.89+/-0.46 vs 2.01+/-0.26 in IH, p<0.001; 1.98+/-0.34 in RH, p<0.001; 1.97+/-043 in IRH, p<0.001). There were no significant differences between the three hypothermia groups with respect to the percentage of necrosis and muscle edema. CONCLUSION: Our results show that local hypothermia applied during ischemic and reperfusion periods is significantly effective in reducing ischemia-reperfusion injury.

Regional bone density changes in anterior cruciate ligament deficient knees: a DEXA study.

Bone mineral density (BMD) loss is one of the secondary problems occurring in knee joint after injury of anterior cruciate ligament (ACL). The effect of this injury on BMDs of specific regions is not clear. The aim of this study was to investigate BMD changes in unreconstructed ACL-deficient knees with subregion analysis of dual energy X-ray absorptiometry (DEXA). Precision and reliability studies of DEXA revealed that two region of interests (ROI) in medial condyle, two ROIs in lateral femoral condyle (LFC) and one ROI in medial tibial plateau (MTP) in anteroposterior (AP) DXA view and one ROI for each of distal femur, proximal tibia and patella in lateral view had high reproducibility and reliability. Thirty-two patients with complete ACL ruptures were collected for the study and uninjured sides served as the control. All the patients were male with a mean age of 30 years. Mean duration of ACL rupture was 24 months. There were significant BMD losses in both ROIs of LFC and ROI of MTP in AP view and all three ROIs of lateral view. Greatest BMD losses in AP and lateral views were at MTP and patella respectively. There was a significant association between patellar BMD loss and duration after trauma. Bone bruises in lateral condyle might be the cause of selective involvement of LFC. Periarticular bone mineral loss in ACL-deficient knees has a predilection for the specified region of interest rather than uniform periarticular loss. This may be important for graft fixation or a factor in tunnel enlargement.

Is there a relationship between anterior knee pain and femoral trochlear dysplasia? Assessment of lateral trochlear inclination by magnetic resonance imaging.

It may be very difficult to diagnose the pathology in patients with anterior knee pain. Patients with chronic anterior knee pain have been reviewed for the study. Our aim was to delineate the presence of subtle trochlear dysplasia by measuring lateral trochlear inclination (LTI) in axial magnetic resonance imaging (MRI) scans. While there were 109 knees in the study group with anterior knee pain (AKP), control group consisted of 74 knees without AKP. The LTI measurements were performed at the level of proximal cartilaginous area of trochlear groove in axial scans. The condition was termed to be trochlear dysplasia when LTI was below 11 masculine. Parameters in both groups were statistically analyzed and compared for their association with LTI. There was no significant difference between LTI values of male and female subjects in each group. The mean LTI values in anterior knee pain and control groups were 17.32 masculine and 21.5 masculine, respectively, and the difference was statistically significant (P < 0.05). The ratio of knees with trochlear dysplasia was 16.5% in AKP group, which was only 2.7% in control. In the AKP group, the ratio of trochlear dysplasia was significantly high (P < 0.05). Although trochlear dysplasia has been generally detected in cases with patellar instability, this study revealed that the frequency of this finding in patients with other causes of anterior knee pain was also considerably high. Measurement of lateral trochlear inclination in axial MRI scans with radiologic assessment seems to be a valuable diagnostic criterion, especially in patients in whom etiology of anterior knee pain could not be identified.

The effect of watching live arthroscopic views on postoperative anxiety of patients.

Surgery is a stressful experience. Many minor interventions have been shown to cause considerable anxiety in patients, but whether arthroscopy leads to such anxiety is not well-known. Methods for lowering perioperative anxiety have been sought and listening to music or watching a movie have been recommended. The method of permitting patients to watch their own endoscopy has been studied infrequently. Our aim in this study was to find out the effect of watching simultaneous arthroscopic views on postoperative anxiety. A total of 63 patients were randomly divided into two groups: those watching their own arthroscopy formed group W, while patients that were only verbally informed formed group NW. The mean age of patients in both groups were 33 and 34, respectively. Meniscal surgery was the most commonly performed procedure (49/63 patients). The patients filled in state scale of State-trait anxiety inventory (STAI) forms and the study questionnaire (SQ) prepared for this study, just before and after the arthroscopy. Group W had significantly lower postoperative scores of STAI-S, whole questionnaire (Q-score) and all but one of individual statements in SQ. Having a previous operation history did not affect STAI scores. Age and level of education was not correlated with any of the studied parameters either. The ratio of patients that were pleased with the arthroscopy experience in group W and NW were 94 and 63%, respectively. Watching live arthroscopic views has led to a significant decrease in postoperative anxiety and worries about the surgery and the postoperative period, while increasing overall understanding and satisfaction of the patient.

Community-acquired infection due to Stenotrophomonas maltophilia: a rare cause of septic arthritis.

Stenotrophomonas maltophilia is an important nosocomial pathogen in hospitalized patients, particularly those with prior broad-spectrum antibacterial therapy. The microorganism mainly infects severely ill, debilitated patients and is most frequent in immunocompromised hosts. A prominent feature of this organism is its resistance to multiple antibiotics including beta-lactam agents, carbapenems and aminoglycosides. Community-acquired infection with Stenotrophomonas maltophilia is reported rarely. This is the first report of a child patient diagnosed with septic arthritis due to Stenotrophomonas maltophilia.

Sagittal plane analysis of the open and closed methods in children with displaced supracondylar fractures of the humerus (a radiological study).

OBJECTIVES: The aim of this study was to compare the radiological outcome of open and close reduction and osteosynthesis methods in the treatment of type II and III supracondylar humerus fractures in childhood with respect to the immediate post-operative reduction quality in sagittal plane. METHOD: One hundred and forty four-pediatric patients with type IIb and III supracondylar humerus fractures treated at two centers between 1995 and 2005 were evaluated radiologically within a retrospective study. Seventy-six patients (54 boys, 22 girls, mean age 7.6, range 2-12) were treated by closed reduction and cross percutaneous pinning while 68 (49 boys, 19 girls, mean age 7.3, range 2-13) were treated by open reduction. The reduction quality of the open and closed groups was compared on immediate post-operative lateral radiographs by measuring of lateral humerocapitellar angle, anterior humeral line and anterior coronoid line criteria. The reduction quality was classified excellent, good, fair and poor according to the achievement of three, two, one or none of the criteria, respectively. Reductions classified as excellent and good were introduced as acceptable results. RESULTS: At least one criterion was achieved in all the patients of both the groups. The mean humerocapitellar angle was 30.1 degrees in closed reduction group while the mean of it was 29.8 degrees in open reduced group. Radiograph of 48 (63.1%) patients with closed reduction were found to display the anterior humeral line intersecting the middle one-third of capitellum while this criteria was 45 (66%) in open reduction group. The anterior coronoid line was disturbed in three patients in each of both the groups. The reduction quality was evaluated to be excellent in 32 patients, good in 31, fair in 13 at the closed reduction group while these evaluations were 31, 20 and 17 in open reduction group, respectively. Successful reduction was achieved in 74.9% of the patients in closed reduction group and 75% of the patients in open reduction group. CONCLUSION: It is concluded that there was no significant difference between closed and open reductions of pediatric displaced supracondylar fractures with regard to the radiological criteria of reduction quality in sagittal plane.

Elephantiasis nostras verrucosa complicated with chronic tibial osteomyelitis.

Elephantiasis nostras verrucosa represents an infrequent clinical entity with cutaneous changes characterized by dermal fibrosis, hyperkeratotic verrucous and papillamotous lesions resulting from chronic non-filarial lymphedema secondary to infections, surgeries, tumor obstruction, radiation, congestive heart failure, and obesity. Although recurrent streptococcal lymphangitis is believed to play a critical role in the origin of elephantiasis nostras verrucosa, the exact pathogenesis of the disorder is not yet clear. Therapeutic efforts should aim to reduce lymph stasis, which will also lead to improvement of the cutaneous changes but unfortunately there is no specific treatment for advanced cases. In this report, we present a patient who was treated by below knee amputation as a result of elephantiasis nostras verrucosa complicated with chronic tibial osteomyelitis.

[The coexistence of fractures of the capitellum and the radial head: a rare case]. / Kapitellum ve radius basi kiriginin birlikte görüldügü nadir bir olgu.

The coexistence of fractures of the capitellum and the radial head in the elbow joint is a rare entity. A 36-year-old man presented with complaints of pain, swelling, and limited range of motion in the right elbow after a fall. Radiography, computed tomography, and three-dimensional reconstruction of computed tomography images revealed displaced and comminuted fractures in the capitellum and the radial head. The fractures were treated with open reduction via a lateral approach and osteochondral fragments were fixed with Herbert screws. Clinical and radiographic results were excellent at the end of a three-year follow-up.

Posterior interosseous artery flap in traumatic hand injuries.

INTRODUCTION: Nineteen cases of posterior interosseous artery (PIOA) flap were reviewed. The patients' mean age was 24 (range 14-53) years. MATERIALS AND METHODS: Nine patients were operated on as emergencies, and 10 patients were treated electively. Mean time of delay after trauma was 7.8 h (range 2-20 h) in emergency cases. Nine of them were non-replantable amputations. Skin defects were between 1.9 x 2.4 cm and 5.0 x 12.0 cm. Mean hospitalization time was 2.2 (range 1-5) days. RESULTS: Mean flap sensation was evaluated as 2.83-6.65 with the Semmes-Weinstein evaluation scale (only 2 patients scored less than 3.61). Five patients presented with discoloration and coolness. Average subjective evaluation was 8.2/10. Mean web opening after first web reconstruction was 40 degrees. One posterior interosseous neuropraxia ( recovered in 4 months), one distal flap necrosis, and one flap lost (due to infection) occurred as early complications. Mean follow-up was 12.8 months (range 15 days to 30 months). CONCLUSIONS: PIOA flap applications have reduced the need for lateral arm and radial forearm flaps and also shortened hospitalization time in clinical practice.

Foucher's first dorsal metacarpal artery flap for thumb reconstruction: evaluation of 21 cases.

BACKGROUND: Coverage of part of a soft tissue defect in the thumb, without bone shortening and without long-lasting immobilization in an inappropriate position leading to stiffness, is difficult to achieve OBJECTIVES: To report our experience using Foucher's modification of the first dorsal metacarpal artery flap for thumb reconstruction in 21 cases. METHODS: Foucher's flap is based on the neurovascular structures of the first dorsal metacarpal artery flap and radial nerve-sensitive branches on the dorsum of the second metacarpal and proximal phalanx. The cause of injury was work-related in all 21 cases. The patients mean age was 37 (range 17-68 years), and mean follow-up was 19 months (range 12-31). Emergency surgery was performed in 13 patients with a time delay after injury of 4-12 hours. The minimum defect was 12 x 18 mm and the maximum 20 x 40 mm. Pedicular length was 55-95 mm. A skin bridge was left intact in 16 cases. In two cases of early postoperative venous congestion and flap loss, a cross-finger flap was performed as a salvage procedure. RESULTS: Subjective satisfaction score was 8.37/10 (range 4-10); cold intolerance was experienced in 60% and dysesthesia in 33%. All except one patient are able to use their thumb in daily activity. Loss of mobility in the proximal interphalangeal joint of the index finger was less than 20 degrees. Semmes-Weinstein sensitivity evaluation score was 3.61-4.31 on the flap and 0-6.65 on the donor site. Two-point discrimination was 10.8 mm (range 8-20). Grip strength was reduced by 15% compared to the unaffected hand (hand dominance was not taken into consideration). Rehabilitation was not consistent as almost all the patients were living in another location. CONCLUSIONS: First DMCA pedicle flap is a successful thumb reconstruction method, especially in patients not disturbed by its cosmetic appearance.