Abstract Thirty eight patients with the acute rupture of the achilles tendon were included in a retrospective study. Twenty five patients had a closed rupture, and 13 patients had open achilles tendon rupture with different sharp agent injury. All patients had unilateral and traumatic rupture of the achilles tendon. All of the patients were operated and cast applied urgently. Patients were followed average 29 months. According to Percy/Conochie criteria patients were evaluated: 17(45%) patients were excellent, 12(31%) patients were good, and 9(24%) patients were fair. There were no rerupture and no severe limp. Two patients had pain while walking, 2 patients had tendon elongation, 9 patients had skin necrosis, 1 deep infection, 11 patients had muscle atrophy, 7 patients had weakness in plantar flexion, 5 patients had more than 10 degree dorsiflexion loss. This surgical treatment in achilles tendon rupture offers satisfactory results , but the fact that thirteen patients (34%) had open rupture of the achilles tendon affecting wound problem and infection rate which were higher than some other series. Özet Kliniğimizde akut aşil tendon rüptürü (ATR) nedeniyle cerrahi tedavi yapılan 38 hastanın sonuçları bu Çalışmada incelenmiştir. Yirmibeş hastada kapalı ATR, 13 hastada ise çeşitli kesici aletlerle oluşan yaralanmalar sonuçla açık ATR hulunmaktaydı. Tüm hastalarda tek tarafta rüptür vardı. Hastalara acilen tendon ta-miri ve uzun bacak alçısı uygulandı. Hastalar ortalama 29 ay takip edildiler. Percy/Conochie kriterlerine göre 17 (%45) hasta çok iyi, 12 (%31) hasta iyi, 9 (%24) hasta orta olarak değerlendirildi. Hiçbir hastada topallama ve tekrar rüptür görülmezken, yürümekle ağrı 2 hastada, tendon elongasyonu 2 hastada, değişik derecelerde cilt nekrozu ve yüzeyel enfeksiyon 9 hastada, derin enfeksiyon l hastada, bacak adelelerinde atrofi 11 hastada, güç kaybı 7 hastada, dorsofleksiyon kaybı 5 hastada tespit edilmiştir. Kliniğimizde ATR de uygulanan cerrahi tedavi ile başarılı sonuçlar elde edilmiştir. Fakat hastaların %34 ünde açık ATR bulunması, yara problemi ve enfeksiyon oranlarının yüksek oluşunda etkili olmuş, uzun immobilizasyon süresi eklem hareketleri ve atrofi yönünden sonuçları etkilemiştir.

Abstract We describe an easy method for distal screw insertion in locked intramedullary nailing procedure and also present the early results of the femoral shaft fractures treated using this method and interlocking nailing. Between 1995 and 1997, 35 femoral shaft fractures which were not suitable for non-interlocked nailing because of localization and comminution were treated by interlocking nailing. The fractures were located in the proximal third of femur in 12 cases, middle in 15, and distal in 8. According to the criteriae of Winquist et al., there were 9 Type I comminution, 8 Type II, 13 Type III and 5 Type IV. For distal locking an easy tecnique modified from freehand technique was used. For tracing of the proximal bone cortex a new pin holder designed to keep the surgeon from radiation was used. The average follow-up was seven months (six to 19 months). There was no nonunions and no need for bone grafting as there was no delayed unions. Two deep late infections (5.7%) were observed. After the complete union the nails were removed, thereafter the infections were cured completely. In one case, incomplete femoral neck fracture occured during the insertion of the nail. The fracture was fixed with three cannulated screws anterior and posterior to proximal part of the nail. The average screening time was 6 minutes (3 to 12 min.). The average operating time was one hour and 45min (45 min. to 4 hours). According to the Thoresen et al.’s criteriae for clinical and radiographic evaluation of the patients, excellent and good results were established in 30 (86%) patients. Conclusions: we concluded that the interlocking nailing of the femoral shaft fractures is one of the best treatment modalities with a wide application range and also using the above described method, distal screw insertion can be performed easily, as well as quickly. Özet Bu çalışmada, kilitli intramedüller çivileme ameliyatlarında distal kilitleme için gelişimleri bir tekniğin tanımlanması ve bu teknikle tedavi edilen, femur cisim kırıkların erken dönem tedavi sonuçları sunulmuştur. 1995 ve 1997 yılları arasında standart çivilemeye uygun olmayan yerleşim ve/veya parçalanma gösteren 35 hastanın femur cisim kırığı kilitli intramedüller çivileme ile tedavi edildi. Kırıkların 12 si proksimal 1/3, 15 i orta 113 ve 8 i distal 113 bölgedeydi. Winquist ve ark.nın sınıflamasına göre, 9 kırık Tip I, 8 Tip II, 13 Tip III ve 5 kırık Tip IV parçalanma gösteriyordu. Komplikasyon olarak, iki hastada geç dönemde belirginleşen derin enfeksiyon ve bir hastada ameliyat sırasında tam olmayan femur boyun kırığı tespit edildi. Ortalama takip süresi 7 aydı (6-19 ay). Hiçbir hastada kırık kaynamaması görülmezken, kaynama gecikmesi nedeniyle kemik greft uygulaması da yapılmadı. Ortalama skopi kullanma süresi 6 dakikaydı (3-12 dak.). Ortalama ameliyat süresi, 1 saat 45 dak. (45 dak.-4 saat) olarak tespit edildi. Hastaların klinik ve radyolojik değerlendirilmeleri, Thoresen ve ark. değerlendirme kriterleri kullanılarak yapıldı. Buna göre 30 hastada (%86) mükemmel ve iyi sonuç elde edildi. Sonuç olarak, kilitli intramedüller çivileme, femur cisminde oldukça geniş bir alanda başarıyla uygulanabilecek bir tedavi yaklaşımı olduğu kanaatine varıldı. Yeni tanımlanan çivi tutucu ve distal çivileme tekniği ile kilitleme işlemi daha kolay ve kısa sürede yapılabilmektedir.

Abstract Objectives: To determine whether there are differences in terms of nerve repair between two different methods of rehabilitation after primary repair of combined injuries in the forearm, namely early controlled motion and immobilization for three weeks.\nMethods: Eleven patients (mean age 31.5 years) with combined injuries in the forearm were treated with early controlled motion after primary repair. Another group of patients (n=14, mean age 32 years) were immobilized. The mean follow-up periods were 32 months and 16.3 months, respectively. For better homogeneity in terms of nerve repair results, those below 20 years of age were not included. The results of nerve repair were evaluated using motor, sensitivity, and functional tests. In addition, the range of finger motion was measured. \nResults: No significant differences were found between the two groups with regard to median and ulnar nerve injuries, the number of injured tendons, the findings of motor, sensitivity, and functional tests, and the range of motion (p>0.05). \nConclusion: Two different methods of rehabilitation after primary repair of combined forearm injuries, with early or late motion, give similar results with regard to nerve repair. Özet Amaç: Önkol kombine yaralanmalarının primer tamiri sonrasında erken kontrollü hareket veya üç hafta tespiti takiben aşamalı hareket şeklinde iki farklı rehabilitasyon yöntemi arasında sinir tamir sonuçları yönünden bir fark olup olmadığını belirlemek.\nÇalışma planı: Önkol kombine yaralanmaları olan 11 hastada (ort. yaş 31.5) primer tamir sonrasında erken kontrollü hareket uygulandı. Başka bir grup hastada (n=14, ort. yaş 32) ise üç hafta tespiti takiben aşamalı hareket uygulandı. Takip süresi birinci grupta 32 ay, ikinci grupta 16.3 ay idi. Sinir tamir sonuçlarına etki eden yaş unsurunda homojenlik sağlamak için 20 yaş altındaki hastalar çalışmaya alınmadı. Sinir tamir sonuçları, motor, duyu ve fonksiyonel testler ile değerlendirildi. Ayrıca, parmak hareket genişlikleri ölçüldü. \nSonuçlar: Ulnar ve median sinir kesileri, eşlik eden tendon kesisi sayısı, duyu, motor ve fonksiyonel değerlendirme testleri sonuçları ve eklem hareket genişlikleri açısından iki grup arasında anlamlı farklılık bulunmadı (p>0.05).\nÇıkarımlar: Önkol kombine yaralanmalarında primer sinir onarımını takiben erken veya geç hareket temeline dayalı iki farklı yöntem de sinir iyileşmesi yönünden benzer sonuçlar vermektedir.

Abstract Objectives: To evaluate the clinical effectiveness of percutaneous autogenous bone-marrow injection in delayed union and nonunion of long bone fractures.\nMethods: In this prospective study, eight patients (2 women, 6 men; mean age 34.3 years; range 20-47 years) who developed delayed union or nonunion of long bone fractures were treated with percutaneous autogenous bone-marrow grafting. The fractures were localized in the tibia (n=3), humerus (n=2), ulna (n=2) and, radius (n=1). \nResults: One patient dropped out of follow-up. Five of the remaining patients achieved sufficient union and healing in a mean duration of 4.2 months (range 3-6 months).\nConclusion: The results suggest that percutaneous autogenous bone-marrow injection is a safe, simple, and effective alternative in the treatment of union problems of long bone fractures in selected patients. Özet Amaç: Perkütan kemik iliği enjeksiyonunun uzun kemik kaynama problemlerinin tedavisinde klinik etkinliğini değerlendirmek.\nÇalışma planı: Uzun kemik kırığı bulunan ve kaynama problemi olan sekiz hasta (2 kadın, 6 erkek; ortalama yaş 34.3; yaş dağılımı 20-47) perkütan kemik iliği enjeksiyonu ile tedavi edildi ve prospektif olarak değerlendirildi. Kırıkların lokalizasyonları tibia (n=3), humerus (n=2), ulna (n=2) ve radius (n=1) şeklindeydi.\nSonuçlar: Bir hasta takipten ayrıldı, kalan yedi hastanın beşinde, ortalama 4.2 ayda (3-6 ay) yeterli kaynama elde edildi.\nÇıkarımlar: Seçilmiş hastalarda, kaynama problemlerinin tedavisinde, perkütanöz kemik iliği enjeksiyonunun, emniyetli, basit ve alternatif bir tedavi yaklaşımı olduğu sonucuna varıldı.

Introduction Carpal tunnel syndrome (CTS) and trigger finger may be seen simultaneously in the same hand. The development of trigger finger in patients undergoing CTS surgery is not rare, but the relationship between these conditions has not been fully established. The aims of this prospective randomized study were to investigate the incidence of trigger finger in patient groups undergoing transverse carpal ligament releasing (TCL) or TCL together with distal forearm fascia releasing and to identify other factors that may have an effect of these conditions. Materials and Method This prospective randomized study evaluated 159 hands of 113 patients for whom CTS surgery was planned. The patients were separated into 2 groups: group 1 (79 hands of 57 patients) undergoing TCL releasing only and group 2 (80 hands of 56 patients) undergoing TCL and distal forearm fascia releasing together. The age and gender of the patients, dominant hand, physical examination findings, visual analogue scale (VAS), and electromyography (EMG) results were recorded. Follow-up examinations were made at 1, 3, 6, 12, and 24 months for all patients. We noted development of trigger finger in the surgical groups, and its location and response to treatment. Results The incidence of trigger finger development was statistically significantly different between group 1 and group 2 (13.9% and 31.3%, respectively). The logistic regression analysis of factors affecting the development of trigger finger posttreatment found that the surgical method and severity of EMG were significant, whereas the effects of the other factors studied were not found to have any statistical significance. Conclusion There was an increased risk of postoperative trigger finger development in patients undergoing TCL and distal forearm fascia releasing surgery for CTS compared to those undergoing CTL only. There is a need for further studies to support this result and further explain the etiology.

BACKGROUND:In upper and lower extremity fractures and osteotomy fixation, the use of methyl methacrylate (MM) as an external fixator presents an alternative method. The primary aim of this retrospective study was to evaluate the midterm outcome of pediatric patients who underwent corrective humeral supracondylar lateral closing-wedge osteotomy, with the external fixation system composed of MM and multiplane K-wires.METHODS:Fourteen consecutive cases with cubitus varus, who underwent corrective osteotomy with a limited lateral approach stabilized with MM and the multiplane K-wires external fixator system between January 2006 and May 2010, were retrospectively evaluated. Time of union, preoperative and postoperative elbow range of motion, and humeroulnar angle were measured. Results were rated as excellent, good, or poor, according to Bellemore criteria.RESULTS:There were a total of 6 female patients and 8 male patients with a mean age of 5.7 years (range, 3 to 9 y). The mean follow-up period was 28.2 months (range, 24 to 48 mo). The mean humeroulnar angle was (-) 18.6 degrees preoperatively, and (+) 16.3 degrees at the final follow-up. Thirteen patients were evaluated as excellent and 1 patient as good, according to Bellemore criteria. Union was seen in all patients at mean 7 weeks (range, 6 to 8 wk). Pin tract infection was observed in 1 patient and treated with oral antibiotics. Loss of correction was not observed in any patient during follow-up.CONCLUSIONS:External fixation of corrective supracondylar humeral osteotomy with MM and multiplane K-wires is a practical, effective, reliable, and cheap alternative method that can be applied.LEVEL OF EVIDENCE:Level IV. Retrospective study.

Purpose. The appearance of trigger finger after decompression of the carpal tunnel without a preexisting symptom has been reported in a few articles. Although, the cause is not clear yet, the loss of pulley action of the transverse carpal ligament has been accused mostly. In this study, we planned a biomechanical approach to fresh cadavers.Methods. The study was performed on 10 fresh amputees of the arm. The angles were measured with (1) the transverse carpal ligament and the distal forearm fascia intact, (2) only the transverse carpal ligament incised, (3) the distal forearm fascia incised to the point 3 cm proximal from the most proximal part of the transverse carpal ligament in addition to the transverse carpal ligament. The changes between the angles produced at all three conditions were compared to each other.Results. We saw that the entrance angle increased in all of five fingers in an increasing manner from procedure 1 to 3, and it was seen that the maximal increase is detected in the middle finger from procedure 1 to procedure 2 and the minimal increase is detected in little finger.Discussion. Our results support that transverse carpal ligament and forearm fascia release may be a predisposing factor for the development of trigger finger by the effect of changing the enterance angle to the A1 pulley and consequently increase the friction in this anatomic area.Clinical Relevance. This study is a cadaveric study which is directly investigating the effect of a transverse carpal ligament release on the enterance angle of flexor tendons to A1 pulleys in the hand.

Aneurysmal bone cyst (ABC) is a locally agressive tumor-like lesion of the bone. Sacral location is rare. Currently recommended treatment for a benign ABC lesion is complete intralesional curettage with or without selective arterial embolization and attempt to salvage unilateral sacral 2-5 roots. A 14-year-old girl presented with severe pain and a large mass in her lower lumbosacral region. Imaging studies demonstrated a destructive lesion, arising from the second sacral vertebral level, extending posteriorly and bilaterally into the gluteal muscles, and anteriorly into the pelvis. Open biopsy established the diagnosis of ABC. Marginal extra-capsular resection via a combined anterior and posterior approach, and postoperative radiation therapy were performed. The patient was pain-free, and no evidence of local recurrence was detected at the 84-month follow up postoperatively. Marginal extra-capsular resection and adjuvant radiotherapy are thought to be effective for the treatment of this large ABC of the sacrum.

Necrotizing fasciitis (NF) and myonecrosis is a potentially lethal soft tissue infection characterized by extensive muscular, fascial and subcutaneous tissue necrosis. In this paper, we report an 18-month-old boy admitted to a health clinic three days after Hepatitis-B vaccine injection with cellulitis at his left lateral arm and axilla. He was recommended oral antibiotics, however in the fifth day after vaccination he became lethargic, there were pseudo-paralysis, edema, crepitus on palpation and cutaneous necrosis was observed at axillary region and at posterior arm. With the diagnosis NF and myonecrosis, all the necrotic tissue including pectoralis major, triceps brachii, and most of the rotator cuff muscles were excised. After cutaneous grafting, the wounds healed, but functional recovery of the shoulder joint was poor at 4 year follow-up. Early diagnosis of NF and myonecrosis with debridment of necrotic tissue can prevent severe life threatening complications

Objectives: The purpose of this study was to assess the suitability of the rabbit knee as a small joint model for the human interphalangeal and metacarphophalangeal joints of the hand.Methods: The proximal joint surface areas of 47 middle phalanges, the proximal and distal joint surface areas of 90 proximal phalanges, and the distal joint surface areas of 42 metacarpals of various human cadavers were calculated and compared with the distal femoral and proximal tibial joint surface areas of 20 knee of 10 New Zealand white rabbits by a photogrammetric method.Results: The mean joint surface area of the rabbit proximal tibia was larger than the proximal joint surface area of the middle phalanx, the distal joint surface area of the proximal phalanx, the proximal joint surface area of the proximal phalanx, and the distal joint surface area of the metacarpal. The mean joint surface area of the rabbit distal femur was larger than that of the middle phalanx, but similar to the proximal joint surface area of the proximal phalanx, and that of the distal metacarpal and distal proximal phalanx.Conclusion: The rabbit knee is not suitable model for the human interphalangeal and metacarphophalangeal joints of the hand. There is still a lack of an appropriate animal model for the small joints of the hand.

This article describes the concomitant presence of two anomalous forearm muscles in a 20-year-old man, discovered accidentally during an operation for a forearm injury. The first one was similar to a reverse palmaris longus muscle except for its direction to the Guyon's canal. The second one originated from the radial antebrachial fascia, superficial to all other forearm muscles in the lower half of the forearm, then diverged medially and extended into the Guyon's canal and was innervated by the ulnar nerve. The patient had no symptoms related to overcrowding of the Guyon's canal before the injury. A hand surgeon should be well informed about the anatomic variations of the hand to be comfortable during surgical practice.

Background: The literature is scarce on wrist tourniquets. In this study, three well-established locations of tourniquet setting including upper arm, proximal forearm, and wrist were compared on the same limb using both clinical as well as biochemical variables in paramedical volunteers.Methods. Twenty unmedicated, healthy, paramedical, right-hand dominant volunteers participated in the study. The left upper arms were used for monitoring. Blood pressures and heart rates were monitored and recorded before (baseline) and immediately after the application of the tourniquet, every 5 minutes, and at the time the patient requested deflation. An intravenous cannula (22 G) was placed on the right hand to obtain samples, which were taken at baseline and immediately after deflation of the tourniquet to evaluate the levels of pO(2), pCO(2) O-2 saturation, pH, bicarbonate, blood sugar, lactate, hematocrit, and electrolytes. The tourniquets were applied to the right upper arm, forearm, and wrist of each subject with 5-day intervals between each trial. Subjective discomfort and tourniquet pain levels were recorded. For each trial, tourniquet tolerance and details of discomfort were recorded. Statistical analysis was performed as appropriate.Results: Twenty volunteers aged 20 to 44 years were included. For each trial, in the first 10 minutes after inflation of the tourniquet, the heart rate and systolic blood pressure were increased compared with baseline values. Diastolic blood pressure was elevated immediately after inflation and remained so until deflation in each trial. Diastolic blood pressure values were higher in the upper-arm tourniquet group compared with wrist. Then pH, pO(2), and O-2. saturation values were de-creased and pCO(2) and lactate levels were increased compared with baseline values in each trial. Blood sugar was decreased significantly in the arm group. The decrease in pH, pO(2), O-2 saturation, and blood sugar in the upper arm group was significantly higher compared with wrist and forearm groups. The lactate value was higher in the upper arm group compared with wrist. Visual analog scale and numerical rating scores were lower in the wrist group compared with others at all times. The longest tourniquet tolerance was in the wrist group. In the wrist group, curling was observed in all subjects but the fingers could easily be extended.Conclusion: The wrist tourniquet is the most comfortable technique of bloodless surgery for procedures limited to the hand region.

The objective of this study was to assess the correlation between neurogenic intermittent claudication (NIC) in LSS and different positions as well as loading status, using the treadmill device. The study was a prospective clinical trial on lumbar spinal stenosis (LSS) using a treadmill equipment. The study population comprised of 80 LSS patients with a mean age of 61. The equipment included a treadmill, unloading station and loading vests. The patients were instructed to walk in five different positions. The initiation time of symptoms and total walking time were recorded. The examination was stopped after 20 min or at the onset of severe symptoms. In order to obtain pretest demographic data on subjects, visual analog scale, Roland–Morris questionnaire, pain disability index, and Beck depression index were used. The initiation time of symptoms (ITS) and total walking time (TWT) were measured during the test. Unloading provided a longer and loading a shorter ITS and TWT. Decline or incline positions did not affect ITS or TWT. The changes in posture had no correlation with the appearance of symptoms in LSS patients with NIC on a treadmill in this study, rather ITS and TWT were determined by axial loading and unloading.

Trapeziometacarpal osteoarthritis predominantly affects middle-aged women. Most cases with rhizarthrosis can be managed successfully by conservative means. The purpose of this prospective study was to evaluate pain and tolerability of viscosupplementation therapy with hyaluronic acid (HA) for trapeziometacarpal osteoarthritis. Groups A and B consisted of eight patients each with Eaton stage 3 or 4 rhizarthrosis, who underwent one cycle of three injections of (one per week) 0.3 cm(3) sodium hyaluronate. The injections for group A were under fluoroscopy control, but fluoroscopy was not used in group B. Pain and tolerability of both groups A and B were measured and compared. The patients of the groups were also asked to evaluate the tolerability of the treatment. The results suggested that HA injection in the carpometacarpal joint is a tolerable procedure but the patients complained of pain and discomfort during the injections. The pain in group A was much greater than in group B. Viscosupplementation for the treatment of trapeziometacarpal osteoarthritis is a viable treatment option for stages 3 and 4 patients when they do not want to be operated on. It is a tolerable but not a painless procedure especially when it is done without fluoroscopy control. We recommend giving injections under fluoroscopy control.

A 20-year-old pregnant woman was admitted to our department with symptoms of deep venous thrombosis in the left lower extremity and excessive lumbar pain. Low-molecular-weight heparin was administered. She recovered with this treatement, however, severe lumbar pain continued. A lumbar magnetic resonance imageg showed dilated epidural veins compressing the roots and acute thrombosis of the inferior vena cava extending to renal veins. During the same period she had acute deep venous thrombosis in her right leg. An urgent venous thrombectomy was performed. Sciatica and deep venous thrombosis resolved after the operation. Low-molecular-weight heparin was administered until the end of her pregnancy.

BACKGROUND We evaluated the clinical and functional results of nerve repair in patients with combined tendon-nerve injuries of the forearm. METHODS The study included 68 patients (58 males, 10 females; mean age 33.5 years; range 5 to 48 years) with combined tendon-nerve injuries of the forearm. A total of 96 nerves were repaired. Patients with nerve defects were excluded. Both median and ulnar nerves were injured in 17 patients; median and ulnar nerve injuries were detected in 17 patients and 34 patients, respectively. The mean time to operation was four hours (range 20 min to 24 h). Primary nerve repair was performed in 60 patients, and secondary repair was performed in eight patients. The interfascicular technique was employed in 18 patients, and epiperineural suture in 50 patients. Rehabilitation included early motion using the Washington regimen. A modified MRC (Medical Research Council) motor and sensory classification system was used for postoperative evaluation. The mean follow-up was at least two years. RESULTS The modified MRC results were as follows: of 17 patients with median nerve injuries, 10 had excellent, seven had good results. Of 34 patients with ulnar nerve injuries, the results were excellent in nine, very good in 10, good in 10, and fair in five patients. Of those with median and ulnar nerve injuries, four, seven, and six patients had excellent, very good, and good results, respectively. Overall, 61 patients (89.7%) had satisfactory results. A significant correlation was found between age and the MRC results (p=0.016). CONCLUSION Primary nerve repair followed by early motion results in substantial rates of excellent and satisfactory results in patients with combined nerve-tendon injuries.

Epidermoid cyst in a long bone is an extremely rare condition. The authors describe such a tumor located in the cortex of the tibia in a 21-year-old woman. She was successfully treated with curettage and autogenous bone grafting.

BACKGROUND:There is no consensus on best treatment of advanced tuberculous coxarthritis in young patients.PATIENTS AND METHODS:We report our results concerning hip arthrodesis for advanced tuberculous arthritis of the hip in 32 adolescents. The operation was preceded by standard antituberculous chemotherapy for 4 weeks, which was continued for 12 months after surgery. At the last follow-up, clinical and radiographic examinations of the ipsilateral knee, contralateral hip and lower back were done. We evaluated function, limitations, and presence of pain with our usual questions.RESULTS:Their average age at the time of operation was 16 (12-18) years and the average duration of followup 12 (10-18) years. Solid bony fusion occurred in all patients after mean 5 months and no complications developed in the postoperative period. 28 patients were satisfied with the fused hip. No patients had reactivation of tuberculosis in any part of their body. The results were comparable to those of arthrodesis performed for other causes.INTERPRETATION:Hip arthrodesis is an alternative method of treatment for advanced stages of tuberculous coxarthritis in the adolescent.