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.

Gouty arthritis at interphalangeal joint of foot after sildenafil use: A case report.

INTRODUCTION: Interphalangeal joint of foot is a very unusual location for gouty arthritis and sildenafil use may cause this phenomenon. PRESENTATION OF CASE: A 58-year-old hypertensive man was admitted to hospital with pain and swelling over interphalengeal joint of his right great toe. His health history included the use of diuretics for a long time and his last gout attack was two years ago at first metatarsophalengeal joint of right foot. Sildenafil, a selective inhibitor of phosphodiesterase type 5 (PDE5), was administered in case of erectile dysfunction for two months. Subsequently, he had several episodes of pain and swelling at first interphalangeal joint of right great toe. Both the onset and recurrence of symptoms were just seen the day after sildenafil use. The patient was free of symptoms after discontinuation of the drug. After an initial evaluation, gout was diagnosed on the basis of synovial fluid analysis. DISCUSSION: This case demonstrates a rare location of gouty arthritis with an uncommon etiology: sildenafil. Regarding the clinical data, the discussion was made to expand the horizon for diagnosis of patients with similar symptoms, to identify risk factors for gout relevant to elderliness, and to review the management of gout. CONCLUSION: Sildenafil use may cause gouty arthritis, and surgical decompression may be helpful for definitive diagnosis and symptom relief in atypical presentation of gout.

Neural fibrolipoma of the digital nerve: a case report.

A 32-year-old woman underwent microsurgical resection of a neural fibrolipoma of the digital nerve of the ring finger. At the 6-month follow-up, the patient had good recovery, no recurrence, and preservation of neural function. Caution should be exercised while planning microsurgical dissection on soft-tissue masses of fingers and hands. Total resection of the lesion and nerve grafting should be avoided.

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.

Unicameral bone cyst of the lunate in an adult: case report.

We report a case of a symptomatic unicameral (simple) bone cyst of the lunate in a 42-year- old woman. The lesion was treated with curettage and cancellous autogenous iliac bone grafting. At five years of follow-up the wrist was pain free, there were no limitations of motion, and the radiographs showed complete obliteration of the cavity. To the best of our knowledge, no other unicameral bone cyst of the lunate has been reported in an adult. Cysts with significant cavities at the carpal bones in an adult should be approached cautiously, as they may require early curettage and bone grafting for healing, before collapse and degenerative changes occur.

The use of combined lateral and medial releases in the treatment of post-traumatic contracture of the elbow.

Elbow stiffness is a common disorder, which restricts daily activities. Between 30 degrees and 130 degrees of elbow movement is usually enough to perform most daily activities. However, a 10 degrees to 15 degrees loss of elbow extension may be a problem when the patient is an athlete. From 1996 to 2004, 20 elbows of 20 patients (who were available for follow-up examination) were treated by lateral and medial release at Kocaeli University, for post-traumatic elbow contracture. Preoperative and the postoperative 12-month follow-up measurements were performed. The mean preoperative arc of motion was 35 degrees and this value improved to 86.2 degrees . The maximum improvement at the arc of motion was 105 degrees . In an effort to understand the pathophysiology of the condition, surgical approaches may be used safely. The purpose of this study was to assess the functional outcome of the elbow joint after using a combination of lateral and medial approaches to treat elbow stiffness.

Accessory lateral discoid meniscus.

The lateral meniscus tends to have more developmental variation than the medial counterpart. This is a report of an accessory discoid layer of lateral meniscus. All arthroscopic, magnetic resonance imaging and histopathological views are presented.

Longitudinal incision in surgical release of De Quervain disease.

The objective of this paper is to contrast the use of a longitudinal incision in surgical decompression of De Quervain disease with a transverse incision. The advantages are ease in recognition of compartment variations and superficial branches of radial nerve and prevention of palmar tendon subluxation by permitting a more dorsal release of the compartment sheath. Since 2002, we have used a longitudinal skin incision instead of the classic transverse incision to release the first dorsal compartment.

Upper-extremity digital amputation secondary to non-traumatic ischemia.

In an attempt to evaluate the factors that result in upper-extremity digital amputation secondary to acute non-traumatic ischemia, nine patients with digital amputations secondary to septic or non-septic emboli were evaluated retrospectively. Although some evidence was present in three patients, no primary focus of emboli could be confirmed in six cases. All patients were consulted about hand surgery > or = 7 days following the clinical suspicion of ischemia for different reasons. No patient had cardiac disease that might result in emboli. The most important factor that resulted in unfavorable prognosis was unknown or unproven primary focus of the emboli, including septic emboli. As a consequence, delay in recognition of the ischemia affects the outcome. Age, gender, and health condition before the incidence did not affect the outcome. Health condition of the patient at the time of diagnosis affects the outcome, as life-threatening conditions change the focus of attention and result in late recognition of the ischemia. Upper-extremity digital ischemia needs a high index of suspicion in cases with unknown or unproven primary focus of the emboli. Prompt recognition and early consultation seem necessary to prevent or reduce the extent of the amputation.

Total destruction of the fourth metacarpal bone by aneurysmal bone cyst: reconstruction with strut fibular graft--a case report.

Total destruction of the fourth metacarpal bone by aneurysmal bone cyst is presented. Despite the benign nature of the lesion on plain radiograms, magnetic resonance imaging (MRI) has revealed total destruction of metacarpal bone with shelling off the articular cartilages on both ends of the metacarpal. Both adjacent dorsal interosseous muscles were also involved with tumour. After removal of the metacarpal bone and third and fourth interossei, fibular bicortical strut graft was used for reconstruction. Arthrodesis was done both at the carpometacarpal and metacarpophalangeal (MCP) joints. The follow-up radiograms at one year revealed excellent incorporation of the graft with no evidence of local recurrence. A careful pre-operative work-up including MRI seems necessary even in lesions that look typically benign with intraosseous location on plain radiograms. This approach may prevent unpredicted morphologic picture during surgery, high recurrence rate and the number of operations.

A very large Schwannoma originating from the median nerve in carpal tunnel.

Schwannomas are common benign nerve tumors occurring in the peripheral nerves. A very large schwannoma of more than 5 years duration, originating from the median nerve in the carpal tunnel in a 38-year-old woman, is reported. There was a painful mass, 60 mm in length and 42 mm in diameter, on the palm without signs of sensory disturbance or atrophy on the thenar muscles. Surgical removal was performed under high-power magnification by separating the sensory and motor fascicles from the tumor. Histological examination resulted in a Schwannoma. At 4-year follow-up, the patient was asymptomatic with excellent relief of symptoms. The tumor did not recur. Although cases have been reported in the literature, this is one of the largest ever described without any neurologic deficit.

[The mid-term results of proximal row carpectomy in the treatment of degenerative wrist joint derangements]. / Dejeneratif el bilegi eklemi patolojilerinin tedavisinde proksimal sira rezeksiyon artroplastisinin orta dönem sonuçlari.

OBJECTIVES: We evaluated the mid-term results of proximal row carpectomy (PRC) in patients who underwent treatment for wrist joint derangements. METHODS: Nine patients (4 men, 5 women; mean age 38 years; range 23 to 66 years) underwent PRC to relive pain in the wrist joint and to improve motion and grip strength. Indications for surgery were acute transscaphoid-perilunate fracture dislocation in one patient, formerly unreduced perilunate fracture dislocation in one patient, Kienbock's disease in four patients, and scaphoid nonunion associated with scapholunate advanced collapse (SLAC) in three patients. The duration of the symptoms ranged from eight months to 10 years. The results were assessed with the use of pre- and postoperative clinical and radiographic studies, and measurements of active and passive motion, grip strength, and pulp and key pinch strengths. The mean follow-up was 35.4 months (range 13.5 to 72 months). RESULTS: Postoperatively, pain relief was achieved in all the patients and no complications were encountered in the early period. One patient with acute transscaphoid-perilunate fracture dislocation developed radiocapitate joint degeneration three years after surgery and underwent total wrist arthrodesis. Compared to the uninvolved side, wrist functions were found adequate with painless motion, except for passive radial deviation which exhibited a significant decrease (p<0.05). Age, sex, and the duration of symptoms did not influence postoperative results. CONCLUSION: In selected patients with wrist joint derangement, PRC enables painless and adequate motion and grip strength for daily activities. However, radial styloidectomy seems to be necessary to prevent restriction in radial deviation.